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Health Questionnaire
Health Questionnaire For Allergy Testing
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* Indicates required question
Email
*
Your email
Surname
*
Your answer
ForeName
*
Your answer
Address,Town,County,Post Code.
*
Your answer
Email
*
Your answer
Phone Number ( Mobile and Landline )
*
Your answer
Phone number
*
Your answer
Date of Birth
*
Your answer
Presenting Problem ( Why are you having a Treatment/Test ? )
*
Your answer
Doctors Name and Surgery
*
Your answer
Current Medication if any ?
*
Your answer
Operations and Dates /Camera Investigations
Your answer
Please tick if you have any of the following
*
Allergies
Acne
Bloating
Blood Pressure ( High or Low )
Cancer
Constipation
Candida /Thrush
Catarrh
Colitis/Crohns Disease
Diarrhoea
Depression
Dizziness/Fainting
Diabetes Type 1 or 2
Eczema /Psoriasis
Gall Stones
Hemorrhoids /Fisures /Fistulas
Heart Problems
Hay Fever
Homonal Problems /Menoupase /Thyroid
Insomnia
Kidney Stones/Kidney Infections
Loss /Gain of Weight
Lung Problems
Liver Troubles
Itching
Indigestion /Acid Reflux
Rectal Bleeding
Mucus
Vision Problems
Ulcers
Required
Do you have Bowel Movements
*
Daily
X2 or More Daily
Every 2 Days
Every 3 Days
Weekly
Required
Do you take any Health Supplements,if so what ?
*
Your answer
Diet ( Please give a general idea) Like Breakfast, Lunch and Evening Meal also what Drinks ?
*
Your answer
Recommended By ? Date :
*
Your answer
A copy of your responses will be emailed to the address you provided.
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