Health Questionnaire

This Questionnaire will take around 30 mins to fill out. It can seem daunting to answer so many questions but your optimal health and wellness is my primary concern and the answers you give here will help me to make sure that you are on the correct course of treatment.

Please don't worry if you don't know the answers to some questions. Just fill out as much as you can. 

Some questions may be repeated twice in different sections. Please do your best to fill out each section, even if it is a duplicate answer. 

Personal Details

Presenting Information

Health History

Family Health History

Please list any major conditions / illnesses that the following people have or had

Health Appraisal

Your answers to this section of the questionnaire will assist us in gaining information about your current symptoms and health concerns and help us to track changes over the coming months. Please answer all questions, in each section. Write Yes or no and describe the frequency of your symptoms over the previous month.
You may note that some questions are repeated throughout the questionnaire. We would appreciate it if you can answer all questions, as this will ensure the most accurate interpretation of your results. You may however leave a question blank if you are unsure of the answer.

Gastro Intestinal - Stomach Hypo-acidity

How frequently do you experience:

Stomach Hyperacidity

How frequently do you experience:

Small intestine/pancreas

How frequently do you experience:

Colon

How frequently do you experience:

Liver / Gall Bladder / Pancreas

How frequently do you experience:

Symptoms of under-active Thyroid

How frequently do you experience:

Symptoms of over-active Thyroid

How frequently do you experience:

Stress, Fatigue and Adrenals

How frequently do you experience:

Low immunity

How frequently do you experience:

Allergy

How frequently do you experience:

Skin

How frequently do you experience:

Musculoskeletal

How frequently do you experience:

Cardiovascular

How frequently do you experience:

Detox Capacity

For Women Only

How frequently do you experience?

For Men Only