check

Let's Get It All Out In The Open...Tell Us About Your Condition By Clicking "Start" Below

Be as specific as possible and DON'T watch your language. Say it any way that makes you comfortable!

Click the button below to start your PERSONAL ASSESSMENT with Mr. Jackson.

Start

Question 1 of 15

Full Name

Question 2 of 15

What is your GENDER?

A

Male

B

Female

Question 3 of 15

What is your AGE?

A

Puberty - 21

B

22-35

C

36-50

D

51-65

E

66-99

F

100+

Question 4 of 15

Are you  a SMOKER?

A

Yes

B

No

Question 5 of 15

What disease or condition are you dealing with right now? Have you been to the doctor for this condition? What feedback did he/she give?

Question 6 of 15

Describe your daily diet (Be specific)

Question 7 of 15

Are you taking any medications? How often? (List all that apply here - Only Mr. Jackson will see these)

Question 8 of 15

Please describe any major symptoms you've had over the past year. (Be specific!)

Please list ALL the damaging symptoms you experience? Do you have obvious symptoms related to your condition? (Situation has gotten out of control)

Question 9 of 15

How do you feel on a daily basis?

Question 10 of 15

Are you looking for this program to help yourself or someone else?

Question 11 of 15

Please let us know how you ended up with Diabetes Mellitus. Be as honest as you can!

Question 12 of 15

If you have any paperwork related to your labs, tests, or diagnosis, upload it here. 

file_upload
insert_drive_file

Question 13 of 15

Most reliable PHONE NUMBER

Question 14 of 15

Most reliable EMAIL

Thank You For Completing Your Assessment

Thank you for completing this assessment as honestly as possible. This will give us the tools to customize a protocol to help you regain your energy, manage pain naturally, and remedy your disease naturally without faceless hospitals, heartless doctors, and ruthless insurance companies!  We can't make any promises, but we do have undeniable success. 

 

Call The Number Below At The Time and Date You Gave Above or Simply Call Right Now

(702) 744-7798

Confirm and Submit