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Practitioner Product Request - Health Questionnaire
What is the Practitioner Product (including brand) you are requesting?
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Full Name:
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First Name
Last Name
Age:
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Email
*
example@example.com
Sex:
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Male
Female
Indeterminate
Prefer not to say
Your Primary Health Issue
Describe the symptoms, including frequency and duration.
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When did they start?
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Is there anything that effects the symptoms (better or worse)?
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Do you have a family history of these symptoms?
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Your Diet & Lifestyle
How many hours do you generally sleep at night?
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Please enter number
What is the quality of your sleep?
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1
2
3
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6
7
8
9
10
(Out of 10 - where 10 is the best quality)
Overall diet?
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10
(Out of 10 - where 10 is the best quality)
General stress levels?
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1
2
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5
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7
8
9
10
(Out of 10 - where 10 is the best quality)
Do you smoke? If so, how many a day?
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No
Yes 1/day
Yes 1-3/day
Yes 3-5/day
Yes 5-10/day
Yes 10-20/day
Yes 20+/day
Please choose from menu
How many standard drinks do you consume per week?
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None
Yes 1/week
Yes 5-10/week
Yes 10-20/week
Yes 20-30/week
Yes 30-40/week
Yes 40-50/week
Yes 50+/week
Please choose from menu
How many times a week do you exercise?
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None
Yes 1/week
Yes 2/week
Yes 3-4/week
Yes 4-5/week
Yes 5-7/week
Yes 7+/week
Please choose from menu
What sort of exercise / activity do you do?
Please enter type
Please list any allergies you have
Are you pregnant?
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No
Yes
Please choose from menu
Are you breastfeeding
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No
Yes
Please choose from menu
Your Medical conditions
Do you have any of the following?
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Yes
No
Arthritis
Asthma
Chemical sensitivities
Coeliac disease
Diabetes
Epilepsy
Glaucoma
Heart condition:
High blood pressure
Inflammatory Bowel Disease
Lactose intolerance
Stomach ulcers
Thyroid
Other medical conditions
If you have answered yes to any medical conditions above, please provide additional details.
Your Medication History
Medications?
*
Mandatory
Supplements?
*
Mandatory
Do you see a Health Care Practitioner?
Practitioner Name:
Practitioner phone number:
Practitioner email address:
Practitioner address:
Do you have any current Practitioner Prescriptions?
Upload a File
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I agree to the terms and conditions and have read Eden Health Products Privacy Policy
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Yes
Signature
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