Name *: Your Email Address*: Telephone*: Fax, if available*: Brief description of main illness*: Name, address, phone number of your family doctor or primary care giver*: Present medical conditions you now have. Please check all that apply to you: Dementias, Aneurysms, Neurological problems Heart Disease Asthma Allergy's Ulcers Heart attack Cancers Gastric-intestinal problems High blood pressure Low blood pressure Hypoglycemic or low blood sugar Diabetes Hormone level problems Lung or upper Respiratory problems renal or kidney problems Muscle , skeletal or joint problems Urinary tract infections Sexually transmitted diseases Are you pregnant Are you having problems getting pregnant Are you having menstruation problems Prostate infections, enlargement ON A SEPERATE SHEET OF PAPER, ANSWER THE FOLLOWING QUESTIONS AND EMAIL TO ME ALONG WITH THIS QUESTIONAIRE: List all medications you are on or have taken: List all natural substances meds, herbs you are on or have taken: List any and procedures you have gone through: List all tests, scans X-ray, MRI EMG etc and results: List any blood work or other exams you have had done: List all accidents, car, work, home or otherwise: THANK YOU This is be no means a complete list, therefore you may be required to supply additional information as each person's life circumstances vary. You may submit this information at no cost at this time. Upon studying your case, I will contact you, either by Email and or phone. If at that time I am able to determine that there is a possibility I can be of assistance in your quest for better health then you will be required to deposit an agreed upon amount in the posted Bank Account. __________________________________________________ ____________________ Your signature of agreement AND date Payments will be made to: BNC Costa Rica Central America LOCAL 200-01-185-000005-7 INTERNATIONAL 1511-8520-01-00000-56 US Dollars and Costa Rica Colones are accepted!