| Is this consultation for you personally? |
Yes No |
| Age |
* |
| Height |
* |
| Weight |
* |
| What is your reason for this email consultation? |
* |
| How long have you been suffering with this problem? |
* |
| List all symptoms |
* |
| Have you seen a healthcare practitioner on this problem? If so, what did they recommend? |
|
| Do you have any dental problems? |
Yes No
|
| Do you have any sleep problems? |
Yes No
|
| What is your stress level? |
5 or less being mild to moderate 6 or more being severe or chronic |
| List all diagnosed medical problems |
* |
| List all medications you are taking for all health problems |
* |
| Does your family have a history of these health problems? |
Yes No |
| List all supplements you are taking including the brands |
* |
