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Probiotics Questionnaire

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The information submitted in this form will be stored in your member record.

You can then access this information via your members login and update the information at any time.

Name*:

Age*:

Gender:

Email*:

Phone:

Primary Health Complaint

List your allergies:

List your intolerances:

Are you pregnant*:

Yes No

Are you breastfeeding*:

Yes No

List any medication you are taking or have taken in the last 12 months*:

List any supplements you are taking or have taken in the last 12 months*:

Describe your symptoms*:

When did your symptoms begin?*:

Is there anything that makes your symptoms feel better?*:

Is there anything that makes your symptoms feel worse?*:

Do you have a family history of these symptoms?*:

Yes No

Please list any medical conditions that you currently have:*:

Diet and Lifestyle

Describe your diet*:

(how many meals do you eat per day and the types of foods and beverages you consume).

How many hours do you sleep at night?*:

Please rate the quality of your sleep out of 10*:

(where 0 is bad quality and 10 is good quality).

Please rate your general stress levels out of 10*:

(where 0 is no stress and 10 is extreme stress).

Do you smoke or vape?*:

If so, how many times per day do you smoke/vape?

Do you drink alcohol?*:

If so, how many standard drinks do you consume per week?

How many hours of exercise do you do per week?*:

What type of exercise do you do?*:

How and when would you like to be contacted by a health practitioner for discussion of your health questionnaire?*:

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Probiotics Questionnaire

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