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Questionnaire
Tue, 05/04/2010 - 21:36 — admin
Please complete the questionnaire in as much detail as you can. This will allow us to better assist you in achieving your wellness goals.
What are your health & lifestyle goals?:
List your health concerns / conditions:
How & when did your major / main condition occur?:
Have you received any treatment for your major /main concern? Please specify:
Do you have any known allergies eg drugs, food, natural medicines, herbs, vitamins, minerals, or environmental?:
Please list any operations & approximate date:
Please list past / current drug medications and the reason for each:
What nutritional supplements, natural medicines, vitamin or herbs do you take and for what reason?:
What is your weight?:
kg
What is your height?:
m
Do you smoke?:
Yes
No
If yes, how many per day?:
Do you drink alcohol?:
Yes
No
If yes, how many standard drinks per day?:
Do you drink tea or coffee?:
Yes
No
If yes, how many cups per day?:
Do you drink soft drinks?:
Yes
No
If yes, how many glasses per day?:
How much water do you drink per day?:
ml
Are you pregnant?:
Yes
No
What is your blood type?:
O
A
B
AB
Unknown
How often do you exercise for more than 30 minutes?:
Never
Once Weekly
Twice Weekly
Three or more times Weekly
Current Stress Level:
1
2
3
4
5
6
7
8
9
10
1 - very low 5 - moderate 10 - very high
Current Energy Level:
1
2
3
4
5
6
7
8
9
10
1 - very low 5 - moderate 10 - very high
Have you or a direct family member ever been diagnosed with any of the following conditions?:
Diabetes
Heart Disease or Stroke
Asthma
Stroke
High Blood Pressure
Dermatitis or Eczema
Cancer
Autoimmune Disease eg rheumatoid arthritis, Multiple Sclerosis, Lupus, Crohn’s Disease etc
Anaemia
Epilepsy
If yes, give details:
I hereby acknowledge my agreement to the use of Natural Supplements as supplied by Healthboost.:
*
I Agree
Agreement to Use of Natural SupplementsThe use of Natural Supplements is most successful when managed and monitored by your healthcare professional. They are a safe and effective way to treat many conditions. For your safety and to ensure maximum benefits to you, you must be aware of the rare risks involved as with all health care practices. Some of these risks include: diarrhoea, nausea, vomiting, stomach upsets, headaches, dizziness, or a potential aggravation of an underlying condition. Also be aware of any cautions, contraindications and warning listed on particular products. Any suggestions made by Healthboost are made to you in good faith and in an endeavor to support you in achieving your wellness goals. The information supplied is intended to encourage self-awareness and not to replace the relationship between you and your healthcare practitioner. I acknowledge and understand that there could be potential risks, cautions, and contraindications associated with the use of natural products. I am aware that results are not guaranteed and I do not expect Healthboost to be able to foresee all possible risks linked with my product selection.
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