Prostate consultation form

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

Email address*

Country*

Nearest Big City To You*

Date of Birth*

Specify which to use for the consultation + your id: Skype or WhatsApp or Messenger*

How long have you suffered from your prostate problems?*

Describe your symptoms*

What medication(s) are you taking?*

What vitamins/ herbs are you taking?*

Do you exercise? Which and how often?*

Do you eat any organic foods? Which and how often?**

I eat chicken*

I eat pork or beef*

Other meat you eat*

I eat gluten? .. bread, cakes, biscuits, flour products, etc..*

I eat dairy products from cow, goat, sheep, etc..*

I eat tropical fruits (oranges, bananas, kiwi, mangoes, etc..)*

I eat tin food or pre-prepared meals*

	Yes
	No

I always check products labels to make sure I don't eat sugar*

	Yes
	No

I always check labels to make sure I don't eat any harmful chemicals (additives, coloring, etc..)*

	Yes
	No

I smoke*

	Yes
	No

I drink alcohol*

Other Comments

How did you hear about my consultation?*

	Google search
	Other search engine
	Your Blog
	Word of mouth
	Your movies on YouTube
	I have ordered from you before
	Facebook
	Twitter
	I can't remember

Please enter the word that you see below.