General Health Questionnaire

Thank you for being a Health Alert Customer!

The information must be entered in all at one time. The form must be completed before leaving this page.

* indicates a required field.

Please Note: An incomplete or missing form may result in a delayed order.

Your Email Address will be your User Name
Email* (must be a valid email address)
(this email is only for purposes of setting up your free membership and for contacting you in the event we require more information to process your order. We do not share or sell email addresses.)
Password* Password Confirmation*
  • Password Must Contain:
  • six (6) or more characters long,
  • at least one number,
  • at least one lower-case alpha,
  • at least one Upper-case ALPHA,
  • and, at least one special character (~`!@#$%^&_-+=<>)
First Name* Last Name
City*State*Postal Code*
Also use as my Default Address 
[Yes] copies this address to your Customer Information as a default billing and shipping address -- you can change both or either during order checkout.    [No] will not update your Customer Information.

Are you a Currently Licensed HealthCare Professional? — If yes, you may be able to purchase certain products directly from the manufacturer.
License type:
How tall are you? Feet:
Subscription Type:
Are you a Vegetarian?
If Yes, are you open to Non-Vegetarian Supplements?   

Drug or Other Allergies*

Do you have Heart Disease? 
Do you have Diabetes? 
Do you have High Blood Pressure?  

List Your Health Concerns*:

We would like to recommend you print this page before submitting it, so you have a record of what you sent us.

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IMPORTANT: This website is not intended to provide medical advice, and nothing in it should be construed as a therapeutic recommendation or prescription for any disease or symptom. Readers should not attempt self-diagnosis or self-treatment of any kind and should not discontinue any medication or therapy or make any health-related decisions without the advice of a licensed medical physician. Dr. Bruce West, DC and HealthAlert disclaim any liability, loss or risk incurred, directly or indirectly, as a result of the use and application of the contents of this website. If you are unwilling to be bound by this disclaimer, you should leave this site.

These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.