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Practitioner Health Questionnaire

Name

Age

Gender Male Female

Primary Health Complaint

Describe your symptoms,including frequency and duration

When did they start?

Is there any thing that them better or worse?

Is there a family history of these symptoms ?

Diet and Life style

How many hours do you sleep at night?

What is the quality of your sleep(out of 10,where 10 is best quality)

General stress levels(out of 10,where 10 is the highest)

Overall diet(out of 10,where 10 is the healthiest)

Do you smoke? If so,how many a day?

How many standard drinks do you consume per week?

How many times a week do you exercise?

What sort of exercise/activity do you do?

Please list any allergies you have.

Are you pregnant?

Are you breast feeding?

Medical Conditions:Do you have any of the following? Yes No

Medical History

Arthritis

Asthma

Chemical sensitivities

Coeliac disease

Diabetes

Epilepsy

Glaucoma

Heart Condition

High blood pressure

Inflammatory Bowel disease

Lactose in tolerance

Stomachulcers

Thyroid

Other Medical conditions-Give details:

Supplements

Other and/or referring practitioners you see and why?

Practitioner’sname

Phone number

E-mail address

Address

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Bergamot Cholesterol Care

Herbs of Gold

Bergamot Cholesterol Care

As low as $34.13

Qty

- +

Herbs of Gold Bergamot Cholesterol Care has been formulated with Bergamot orange, which contains a unique composition of citrus flavonoids to help support healthy cholesterol.

Bergamot extract 500mg
With Globe artichoke
Helps support healthy cholesterol

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Bergamot Cholesterol Care contains a combination of Bergamot and Globe artichoke to help support healthy cholesterol.
Bergamot Cholesterol Care supports cardiovascular system health.

Each tablet contains:
Citrus aurantium (Bergamot orange) fruit juice extract 500mg

derived from fresh juice
75g
Cynara scolymus (Globe artichoke) leaf extract 60mg

derived from fresh leaf
3g

Adults - Take 1 tablet, twice daily, before main meals, or as directed by your health professional.

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