Prolon Self-Assessment

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1. Are you between the ages of 18 to 70? *

Yes

No

2. Do you have allergy to nuts (macadamia, cashew, almond, pecan), soy, oats, sesame, or celery/celeriac? *

Yes

No

3. Do you have any unique or special health needs or conditions, such as a fever, cough, diarrhea, sign of an active infection, dietary restrictions, or are you are pregnant or breast feeding? *

Yes

No

4. Are you underweight for your height, meaning are you: *

150 - 160 cm and under 45 kg
161 - 167 cm and under 48 kg
168 - 175 cm and under 52 kg
176 - 178 cm and under 57 kg
179 - 183 cm and under 61 kg
184 - 193 cm and under 68 kg

*

Yes

No

5. Do you have any diagnosed chronic medical condition or are you taking medications for any diagnosed condition or disease, such as Diabetes (type 1 or type 2), cardiovascular disease, kidney disease, liver disease or a history of syncope (fainting)? *

Yes

No

Please check this box if you wish to receive helpful tips for making the most of your ProLon 5-Day Fasting Mimicking Diet, updates with new product information, and occasional promotional offers.

*

I certify that the answers that I have provided above are accurate to the best of my knowledge. *

*

I have read the policy privacy. *

Please provide your contact information below:

First Name: *

Last Name: *

Email: *

Phone: *

How did you hear about ProLon? *

Other: * 🛈

Publication: *