* Full Name (First AND Last) * E-Mail Address * Address 

* City   State *   Zip Code *  

Q1. Have you been diagnosed as having tendinitis by a health professional? Yes No

Q2. Are you milk sensitive? (one of our supplements is a milk product derivative, but separate supplements can be substituted)   Yes No

Q3. How long have you had tendinitis? Please Select One 1 -- 3 Years 3 -- 5 Years 5 -- 10 Years More than 10 Years
How did it begin? (Please provide a brief description)

Q4. Are you engaged in activities that continue to aggravate the tendinitis? Yes No
If yes, please explain:

Q5. Have you been off work because of your tendinitis? For how long? Yes No If yes, how long?

Q6. Do you have other disease conditions which might affect your recovery, such as muscle disorders (M.S. M.D.), digestive problems, others?
Yes No If yes, please list the conditions

Q7. Are you taking prescription drugs which could affect your recovery, such as quinalones? Yes No
Please list the prescription drugs you are currently taking:

Q8. Are you taking anti-acids regularly?  Yes No

Q9. Have you had any surgeries that might affect your recovery? Yes No If yes, please list the date(s) and type(s) of surgery:

We need the exact location of your tendinitis; Example Foot, wrist, & arm are not exact locations. Exact Locations Are (Please check all that apply)

Shoulder: Front of shoulder Tip-top center Side of shoulder (deltoid area) Deep in shoulder joint Other

Wrist (two sides, two edges) Palm side (inside) Outside (back or hair side) Thumb edge Small finger edge Carpal tunnel 

Injuries? Yes No

If yes. please explain

Foot: Bottom (plantar fascitis) back or top of foot Back of heel (achilles tendinitis)

Ankle: Left or right side of which ankle? Left Right

Injuries?If yes. please explain

Elbow (epicondylitis) Inside or outside edge Biceps tendinitis (inside center of elbow joint and just above

Fingers: Inside (palm side) Outside or Back side

Knee: Left or right side of which knee? Left Right   Patella (front) upper or lower or both Back of knee (ham strings)

Injuries?If yes. please explain

Any other affected areas? Please explain (list):