ProLon Group
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Email *
Full Name *
Are you...?
Yes
No
allergic to nuts, soy, sesame, or celery/celeriac?
Pregnant or Breastfeeding?
experiencing symptoms or under treatment for an ACTIVE infection or fever?
Malnourished or diagnosed with a protein deficiency ?
Underweight or BMI <19?
on dialysis?
Under 18 or Over 70?
Diagnosed with an eating disorder?
Clear selection
Do you...?
Yes
No
Have Insulin dependent Diabetes? or Brittle Diabetes?
Have NON insulin dependent Diabetes (meds or diet only)?
Have Chronic Kidney disease?
Have Liver Disease?
Have Gout?
Have chronic diarrhea?
Have recurrent syncope (fainting)?
Have exposure to very hot or cold temperatures?
Clear selection
What is your height?
What is your most recent weight?
What medicine or supplements do you take?
Have you ever fasted before?
Have you ever been seen by Dr. Chandler in Haddonfield? *
What is the name of the group or provider that provides primary care (PCP)? *
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This form was created inside of Chandler Wellness Care LLC.