Consultation

What is your full name? *

What is your date of birth? *

What is your gender? *
MaleFemaleOther

What is your phone number? *

What is your email address? *

How often do you exercise? *
Daily3-5 times a week1-2 times a weekRarely or never

What is your typical diet like? *
Mostly fruits and vegetablesBalanced diet with a mix of foodsHigh in processed or unhealthy foods

Are you currently experiencing any symptoms or concerns related to your physical health? *
YesNo (If yes, then please specify

Have you experienced any recent changes in your appetite? *
YesNo (If yes, then please specify)

Do you have high blood pressure? *
YesNo (If yes, then please specify)

Do you have high cholesterol? *
YesNo (If yes, then please specify)

Do you have any allergies to medications or foods? *
YesNo (If yes, then please specify)

Have you ever had a seizure or convulsion? *
YesNo (If yes, then please specify)

Have you ever been diagnosed with diabetes? *
YesNo (If yes, then please specify)

Have you ever had a sexually transmitted infection? *
YesNo (If yes, then please specify)

Do you smoke or use tobacco products? *
YesNo (If yes, then please specify)

Do you consume alcohol? *
YesNo (If yes, then please specify)

Do you use recreational drugs? *
YesNo (If yes, then please specify)

Do you currently take any prescription medications? *
YesNo (If yes, then please specify)

Have you ever had a serious reaction to a medication or vaccine? *
YesNo (If yes, then please specify)

Do you have any concerns about your sleep patterns or quality of sleep? *
YesNo (If yes, then please specify)

Do you experience any breathing difficulties? *
YesNo (If yes, then please specify)

Your message (optional)