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Client health questionnaire

Please fill out the following form
carefully.

First name

Last name

Email

Date of Birth

Todays date:

Please check any box that applies to you:

Anxiety disorders or GAD, panic discorders, phobias

Enteritis or Crohn's syndrome

Mood disorders, depression, bipolarim, cyclotymia, or SAD

Epilepsy or past seizures

Eating disorders, anorexia, bulimia, binge eating disorder

Heart attack or stroke

Schizoaffective disorder

Hypertension or high blood pressur

Multiple personality disorder

Hypo- or hyper-thyroidism

Post-taumatc stress disorder (PTSD)

IBS (irritable bowel syndrome)

Alzheimer's, Dementia, Parkinson's

Insulin resistance or pre-diabetes

Insomia or sleeping disorders

Joint problems, arthritis, or osteoporosis

Exhaustion and chronic fatigue

Chest tightness, shortness of breath, asthma

Intermittent explosive disorder

Lung infection or bronchitis

Amyotophic lateral sclerosis

Low immunity or recurrent infecton

Arteriosclerosis, atherosclerosis or coronary artery diseases (CAD)

Menopausal symptoms

Migraines or headaches

Cancer, lumps, or tumour

Muscle cramping and aches

Cold sors or herpes labialis

Obstipation or constipation

Common cold, viral infectios, or flu.

Podagra, gout, elevated uric acid

Contusions, bruises, burnes, cuts, injury

Pregnant or lactating

Colon inflammation or colitis

Chronic pain or fibromyalgia

Stomach pain, heartburn, reflux, indigestion, or low stomach acid

Calculi or gallstones

Sinus inflammation (sinusitis)

Diabetes (type 1 or 2)

Stomach ulcers

Diverticula inflammation (diverticulitis)

Thrush, fungal infections, or candidiasis

Dermatitis, psoriasis, or skin conditions

Varicose Veins

Excess body fat and obesity

Recent accident or major operation

List Allergies:

Are you taking medications? List them here:

Other health conditions or symptoms:

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It is our opinion and should not be misconstrued as professional or medical advice.

It should not be misconstrued as a product that is intended to heal, cure or treat any diseases.

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All rights reserved, without prejudice. Disclaimer: No products offered on this website are designed for & intended to diagnose, treat or cure and ailment/ “disease.” The purchaser and consumer assumes full responsibility for anything that may result from consuming any product offered on this platform. Always consult with a qualified physician before consuming anything offered on this website, especially if you are at risk/pregnant. If you are on any medication please consult a physician to see if it is safe to use any of these offerings. No product(s) on this website are approved by the Federal Drug Administration (FDA) & by purchasing any product from this website you are agreeing to take full notice of our notice to you, the consumer. These terms are non-negotiable. Please proceed at your own risk.

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