Health Questionnaire

It is essential to see the driving factors behind feeling unwell. This questionnaire will allow you to see what systems in your body are challenged or compromised at the moment, which may be contributing to your current health concerns.

Please select any symptoms that you experience.
You will receive a copy of your State of Health graph, as will the clinic providing this questionnaire, so that you may discuss your health concerns with a professional.

Your information is kept confidential at all times.

Note: All fields marked with a red asterix * are required fields.
Your Details
Name *
Age *
Email *
Phone (if wanting to be contacted by the Clinic)
Diagnosed Medical Conditions (if applicable)
Do you currently take medication for any diagnosed medical conditions?
What is your first concern when it comes to your health? *
Please list what allergies you have:
Please list diagnosed autoimmune diseases:
  • Section One

  • Section Two

  • Section Three

  • Section Four

  • Section Five

  • Section Six

Submit My ResultsClear Form

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