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Adult Supplement Health Questionnaire
Please fill out a health questionnaire and release form prior to consuming our supplements. We advise you to seek medical counsel from your healthcare practitioner prior to taking any supplements. If you would like a more detailed consultation with respect to supplements, please email
hello@postpartumslimdown.com
.
*
Indicates required field
Name:
*
First
Last
Email:
*
Phone Number:
*
Age:
*
Height:
*
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
Are you pregnant?
*
Yes
No
When did you give birth to your last child?
*
Less than one month ago
2 to 3 months ago
4 to 6 months ago
7 to 9 months ago
10 to 12 months ago
1 year to 1.5 years ago
2 to 3 years ago
4 + years ago
I don't have kids!
Are you breastfeeding?
*
Yes
No
If applicable, please specify when you stopped breastfeeding:
*
Are you on any medications?
*
Yes
No
I'm not sure
If yes, please list:
*
List of current medications and/or supplements:
*
List any preexisting health conditions (i.e. anxiety, depression, breast cancer, insomnia, autoimmune, etc.):
*
List any allergies, sensitivities or intolerances to foods and/or medications:
*
Anything else we should know?
*
Please select how you would like to be communicated with:
*
Text
Email
Phone
WARNING: Some of these products may contain ingredients of soy, tree nuts, sardine, anchovy, mackerel. When taking the supplement(s), please follow directions and take recommended doses. We recommend keeping our supplement(s) out of child reach in-case of accidental overdose. If there is an accidental overdose of you or your child, please call a doctor or poison control center immediately. By submitting this form, I agree that any and all information provided above is accurate and true. I agree that I have thoroughly read any and all information pertinent to the supplements being purchased, including ingredients, labels, warnings, allergens, age/height/weight requirements. If agree that I do. not have any preexisting health conditions that would put me in danger as a result of taking the supplements. I agree that I have received medical consent to take such supplements from my healthcare practitioner or a Postpartum Slimdown practitioner in the event that I do have a preexisting medical conditions, am pregnant and/or nursing. I finally release CATE AND ILA, LLC from any damage or injury caused as a result from consuming the purchased supplements taken.
*
I AGREE
Submit
HOME
SLIMDOWN SHOP
SUPPLEMENT SHOP
HEALTH QUESTIONNAIRES
POSTPARTUM SLIMDOWN HEALTH QUESTIONNAIRE
CHILD SUPPLEMENT HEALTH QUESTIONNAIRE
ADULT SUPPLEMENT HEALTH QUESTIONNAIRE
TESTIMONIALS
ABOUT
ABOUT
>
MEET THE FOUNDERS
CONTACT