The Herbal Company

Voluntary Study Form
Please provide general information about yourself, and AVIOD any specific or unique identifying information because the information you provide here may be viewed by others including people like yourself.

DISCLAIMER: The information you provide here is VOLUNTARY, and the firm (The Herbal Company, Inc. and others including, but not limited to their associated companies and advisors) will use the information deemed fit to make improvements to the product(s) offered to general consumer(s). The firm is not responsible for any direct or indirect damage or injury caused to you as a result of your intentional or inadvertant inclusion of personal or unique identifying information.

Name
(Nickname or Initials which can identify your return to update your information)

E-Mail

Sex Male Female

Age

Current Weight (Lbs.)

Desired Weight (Lbs.)

Height ( Select One) cm. ft. in.

Physical Activity Level High Moderate Low

Health Status

Cholesterol

Diabetes No Yes (if YES, what type)

Bowel Movements

Hypertension (High Blood Pressure) No Yes

Are you getting medical help for any of the above? No Yes

Can we contact you by phone? Yes No

Phone

Please inform your doctor that you are taking FENUBER® as a high dietary fiber supplement!

Comments/Questions: