hCG Prescription Questionnaire

These questionnaires are kept on file for 1 year so only fill this out if you haven’t already done so in the last 12 months. Thank you!

Personal Information

Your Name *

Your Email *

Phone # *

Address *

City *

State *

Zip *

Sex *

Height *

Weight *

Desired Weight *

Have you ever been diagnosed/treated for: (if no leave blank)

High Blood PressureSeizures or EpilepsyDiabetesHepatitisHeart Attack or AnginaPanic AttackHeart PalpitationsAnxiety Disorder
Low Blood SugarKidney ProblemsChronic Lung ProblemsAnemiaAsthmaEye ProblemsShortness of BreathThyroid Problems
CancerTriglyceridesFrequent HeadachesBlood DisordersChronic ConstipationNeurological DisordersPMSChronic Fatigue Syndrome
Heart MurmursAny Psychiatric DisorderSwollen AnklesAnorexiaGoutHot Flashes

If you checked any above please provide further details

Lifestyle

How many alcoholic drinks do you consume per week? *

How much caffeine do you consume per day? *

How many diet beverages do you consume per day? *

Do you smoke? * YesNo
How many per day?
If quit, when?

Marital status*: MarriedSingleDivorcedWidowedSignificant Other

Do you feel you eat healthy?* YesNo

Do you follow a special diet?* YesNo

Do you exercise?* YesNo

Do you have stress in your life?* YesNo

Nutrition / Diet

Do you follow a particular diet? * YesNo
If yes, please describe?

Have you gained/lost weight recently? YesNo
If yes, please describe?

Medication Allergies: YesNo
If yes, please describe?

Do you normally eat breakfast? * YesNo

Have you ever tried a weight loss program using hCG in the past? * YesNo

What are the names of weight loss programs/diets that you have tried? *

Which type of diet was the most successful for you? *

How much weight would you like to lose on The HCG Program? *

Please list foods you eat regularly for:



How much water do you normally drink? *

Consent For Treatment With hCG

Enter Initials in each box to verify you understand each topic

The HCG Protocol is for the reduction of excessive weight. A key component of the protocol is the use of hCG (Human Chorionic Gonadotropin). The hCG will be administered orally. The use of HCG for weight loss was first identified by A.T.W. Simeons, M.D. in the 1960s. The publication of his book, Pounds and Inches. The New Approach To Obesity in 1969 has made his protocol available globally. This protocol does include dramatic calorie restriction during the rapid weight loss phase. *

Anticipated Benefit
The HCG protocol is designed to yield rapid weight loss, often reported at 1/2 to 1 pound per day during the weight loss phase of the program. Our protocol includes features to help the maintenance of lean muscle mass during the rapid weight loss phase.

By bringing your weight into a more healthy range (BMI of 18 to 23 for men and 20 to 25 for women) the benefit would include improvement in the bodyʼs maximum functioning with a well known decrease in many health concerns including, but not limited to, risks of developing cancer, diabetes, heart disease and high blood pressure. *

Risks and Complications
Possible side-effects of hCG may include transient headache or allergic reaction. The use of hCG for other medical treatments is at a much higher dosage (as is used during fertility treatment for both males and females). There is no evidence that the use of the small doses in Dr. Simeons protocol has any effect on increasing or decreasing fertility. For clients with high blood pressure who are on medication there is always a concern that they may require a decrease in the dosage of medication as they lose weight because of a natural improvement of blood pressure. For clients with diabetes who are on medication or insulin there is always a concern that they may require a decrease in the dosage of medication as they lose weight because of a natural improvement in blood sugar levels. For clients who are prone to low blood sugar (hypoglycemia) there is a risk that their blood sugar may become low at different times during the day. *

Pregnancy and Breastfeeding (female client)
The use of hCG in the doses used in our protocol will not have any known effect on the clientʼs ability to become pregnant. We do not start treatment on a pregnant woman. If a client becomes pregnant during the treatment she is to discontinue treatment during pregnancy and breastfeeding. Treatment will not be started while a woman is breastfeeding. By signing this consent I assert that I am not pregnant or breastfeeding. *

FDA Disclaimer
The FDA has not approved hCG for weight loss; itʼs use for weight loss is consider an “off label” application. The use of hCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie restricted diets. hCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat, or that it decreases the hunger and discomfort associated with calorie restricted diets. The FDA has not approved hCG for weight loss. *

Additional Nutrients
The client chooses to order hCG and may also use additional vitamins that work in conjunction with the hormone, hCG. Vitamin B-12, Multi vitamins and magnesium. *

I have carefully read and initialed the preceding sections of this consent for treatment with hCG. I understand that the use of hCG for weight loss is not approved by the Food & Drug Administration. I voluntarily consent to the use of hCG. I realize that the doctor nor any personnel of The Joy Ranch Wellness / HCG Buy Direct has made no absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to discontinue participation in this treatment program at any time. I warrant that I have completed this questionnaire truthfully and accurately. My records will be kept confidential.