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B100
About Dr. Bereliani
Q&A
Am I A Candidate
Contact
AM I A CANDIDATE?
FILL OUT OUR FORM BELOW AND A REPRESENTATIVE WILL CONTACT YOU
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1.
What is your age?
2.
What is your gender?
Male
Female
3.
Do you have heart disease or cardiovascular disease?
This includes being diagnosed with angina, a heart attack, a stroke, a mini-stroke (TIA), or peripheral artery disease (PAD).
Yes
No
4.
Do you have family history of heart disease?
Fist degree only, such as mother, father, sister, or brother.
Yes
No
5.
Do you have diabetes?
Yes
No
6.
Do you smoke?
Yes
No
7.
Do you have dependents that you directly care for in your home?
Such as, spouse, children, grandchildren, parents etc.
Yes
No
8.
What is your level of stress?
1 being no stress, 10 being the highest.
9.
What is your job title?
10.
What is your level of commitment to this program?
1 - Not committed, just curious. 10 - Very committed to living to see 100 free from the fear of a heart attack.
11.
What motivated you to want to join the B100 program?
12.
Please provide your name.
13.
Please provide your email address.
14.
Please provide a phone number where we can contact you.
Submit