First Name
Last Name
Email Address
Phone Number
Age
GenderSelect an optionMaleFemale
Describe your symptoms, including frequency and duration.
When did they start?
Is there anything that makes them better or worst?
Is there a family history of these symptoms?
How many hours do you sleep at night?HRS
What is the quality of your sleep? (Out of 10, where 10 is highest)12345678910
General stress levels (Out of 10, where 10 is highest)12345678910
Overall diet (Out of 10, where 10 is highest)12345678910
Do you smoke?NoYes
If yes, how many a day?
How many standard drinks do you consume per week?
How many times a week do you exercise? What sort of exercise/activity do you do?
Please list any allegies you have.
Are you pregnant?NoYes
Are you breastfeeding?NoYes
Do you have any of the following?
YesNo
ArthritisYesNo
AsthmaYesNo
Chemical sensitivities YesNo
Coeliac diseaseYesNo
DiabetesYesNo
EpilepsyYesNo
GlaucomaYesNo
Heart ConditionYesNo
High blood pressureYesNo
Inflammatory bowel diseaseYesNo
Lactose intolorenceYesNo
Stomach ulcersYesNo
ThyroidYesNo
Other medical conditionsYesNo
Give details:
Medications :
Supplements :
Please leave this field empty.
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