(fields marked with * are required)
Please rate severity on a scale of 1-10 (10 being most severe)
Please list any medications you are taking including dosage, length of time and the condition for which you are taking them. Please include any topical medication also.
Please list any supplementation you are taking including length of time taken and dosage.
Please check any digestive symptoms you are currently experiencing:
Have you had any occupational or environmental exposure to toxic metals or chemicals i.e. painting, manufacturing, building, mechanic, carpentry, hairdressing etc?
List the environments that you previously and currently live in i.e. city, farm, next to orchards, tunnels, motorways etc.
List all digestive investigations you have had i.e. barium meals, radiography etc.
Please tick any of the following organs which you have done specific cleanses for in the past year:
What benefits or difficulties did you experience?
Are you currently pregnant or breastfeeding?
Is there anything else that we haven’t asked about that you think is important?
Please leave this field empty.