Intake Form

Full Name *

Your Age *

Email *

Phone *

PRESENTING COMPLAINTS AND/OR HEALTH GOALS. *

MEDICAL CONDITIONS. Do you currently have any diagnosed illnesses, medical conditions? If so, please provide details ? *

MEDICATIONS AND SUPPLEMENTS. Are you currently taking any prescription medication, over-the-counter medication, natural remedies or supplements? Please provide details? *

PREGNANCY AND LACTATION. Are you currently pregnant or breast feeding? Or planning to become pregnant?

PLEASE SELECT IF YOU ARE EXPERIENCING ANY OF THE BELOW

IMMUNE SYSTEM *

Allergies Frequent infections (more than 4 a year) Chronic infections (yeast, fungal) Inflammation Night sweats None

GASTROINTESTINAL SYSTEM *

Heartburn and/or flatulence Abdominal pain Nausea and/or vomiting Constipation Diarrhoea Haemorrhoids Change in weight None

RESPIRATORY SYSTEM *

Catarrh Mucus Blood Pain Cough Breathing difficulties Wheezing None

GENITOURINARY SYSTEM *

Frequency greater than 6 to 8 times a day, and/or 0 to 1 a night Urgency Pain Altered bladder control Menstrual issues Dysfunction None

NERVOUS SYSTEM *

Headaches Dizziness and vertigo Tinnitus Visual disturbances Poor sleep Poor memory None

ENDOCRINE SYSTEM HISTORY *

Diabetes Type 2 Underactive Thyroid Overactive Thyroid None

MUSCULOSKELETAL SYSTEM *

Bone and/or joint pain Muscle pain None

SKIN *

Rashes Itching Dryness Acne Skin tags Discoloration None

Your cart is empty

Your cart

Estimated total

Intake Form