Health History Report
Contact Details Again
Name and Surname
You know the drill, we still need these to be filled in - thanks
Diagnosed by a doctor
Have you been diagnosed with any of the following?
Cardio vascular disease
High Blood pressure
Other Joint Problems
Breathing or lung problems
Any type of diabetes
Digestive issues, constipation, Diarrhoea
Gerd, Acid Reflux, IBS, Functional Dyspepsia, Ulcers
Self diagnosed Pains
Aches, Pains and Problems
Where are you experiencing pain on a regular basis?
Upper Stomach - along the ribcage
Lower stomach - under the belly button
Tinnitus - ringing in ears
Finger joints pain
Non cardiac chest pain
Globus, feels like object in throat
Wake up tired
Suffer with 3'o clock slump
Which of the following supplements are you using?
Energy Fizzy Tablets - vitamin B complex
Energy herbs such as rhodiola, moringa, schisandra etc.
Fat Burner tablet, tea or juice
Joints - to ease joint pain
Meal Replacement Shake - any brand
Mental alertness like ginkgo biloba, Ginseng, L-Theanine etc.
Natural Relaxants for anxiety and panic attacks
Protein like whey, soy, rice, pea etc.
Vitamin C Supplement
Other Supplements not on the list above.
Which allergies do you suffer from
Skin allergy, hives, contact dermatitis, eczema, etc.
Insect stings like a bee sting
Dust mite allergy
Other allergies not mentioned in the list above
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