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Prolon Self-Assessment
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1. Are you between the ages of 18 to 70?
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Yes
No
2. Do you have allergy to nuts (macadamia, cashew, almond, pecan), soy, oats, sesame, or celery/celeriac?
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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?
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Yes
No
4. Are you underweight for your height, meaning are you:
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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
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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)?
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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.
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I certify that the answers that I have provided above are accurate to the best of my knowledge.
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*
I have read the
policy privacy
.
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Please provide your contact information below
:
First Name:
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Last Name:
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Email:
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Phone:
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How did you hear about ProLon?
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Health Care Provider
Family Member
Friend
Facebook
Twitter
Instagram
YouTube
Pinterest
Reddit
Publication
Interview
The Longevity Diet book
Online Advertising
Google search
L-Nutra
Fasting documentary
Other
Other:
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🛈
Publication:
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Mind Body Green
The London Times
Science Daily
StatNews
Yahoo! Finance
Other
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