SIGN UP Below To Receive FREE Hope Beyond Fibroids Elimination Teleseminar MP3
ELIMINATE Your FIBROIDS and/or INFERTILITY Issues in 90 Days!
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Full Name: *
Email Address: *
Mobile Number: *
Full Address:
Age *
How Did You Hear About Us/Our Program? (Check All That Apply) *
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How Do You Feel About Incorporating Prayer & Scripture Into Your Coaching? *
Which Best Describes Your Issue? *
If you have Fibroids, how many and what sizes are they according to your most recent test and what date did that take place? *
As much as possible, please provide exact details on the number, size and location if known.
Medical Overview of Your Story/Case *
Please include dates to provide a timeline where possible--also identifying any surgeries and/or advanced reproductive technology treatments (such as IUI or IVF) you have undergone.
What is Your Current Physical Condition? *
Symptomatic
Asymptomatic
What Are Your Most Severe Symptoms? *
What Is Your Current Emotional Condition? *
Fearful
Happy
What is the Main Driver of Your Emotional Condition? *
What is Your Current Spiritual Condition? *
Hopeless
Hopeful
What is the Main Driver of Your Spiritual Condition? *
Do You Exercise Regularly And if So How Often and What Kind of Exercise? *
What Best Describes Your Diet? *
What Time Zone Are You In and What Times of Day Monday through Friday Are You Available for Coaching Sessions ? *
Required
What Best Describes Your Budget for This Treatment? *
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Do You Have Any Other Medical Issues That We Should Be Aware Of? *
Please Check ALL That Apply.
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What, If Any, Medications Are You Currently Taking and What Do They Treat?
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