Please tick and complete where appropriate. Leave blank if information is not relevant, not known or you would prefer not to answer the question.
Before you advise us of the detail of your health status please take a moment to consider;
WHAT WOULD OPTIMAL HEALTH LOOK LIKE FOR YOU? HOW WOULD THINGS CHANGE FROM NOW?
We will use this information to help us understand you better and to set health goals together
What are the main health issues you would like us to focus on?
What would you like to learn about or achieve? (eg more energy, lose weight, relax more, live longer)
Your medical history
Do you now or have you ever experienced any of the following?
On testing have you ever found the following?
Have you had, or do you currently have, any of the following infections?
Have you had any of these removed?
Have you had any of these surgical procedures?
Your toxic panel
Which of the following vaccinations have you had?
Have you ever had any travel vaccinations?
Digestion and nutrition
What does your typical day’s diet look like?
Please indicate how these statements describe you;
How many caffeinated drinks do you have daily?Please indicate number of cups per day in the boxes
Do you currently take any nutritional supplementation?
Energy and sleep
Female hormones - ANSWER IF APPROPRIATE
Do you suffer from any of these linked to your cycle?
Mind, mood and stress
You have reached the end of the form.
Please click the 'Submit Form' button below to send it to Health Optimising (UK) Ltd
You can also print the form to keep for your own records.