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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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Liquid Stevia Lemon

Nirvana Organics

NVSF106

As low as $14.95

Qty

- +

Liquid Stevia Lemon Flavour Sweetener is made with 100 percent certified organic stevia extract and all-natural butterscotch flavouring, this deliciously sweet liquid stevia is bursting with flavour without the calories. Simply add a few drops for extra flavour and sweetness to all your favourite food and drinks. This liquid stevia is great for coffee, tea, smoothies, milkshakes, yoghurt and desserts.

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100 Percent natural stevia sweetener with Lemon flavour
Provide extra flavour and sweetness without the extra calories
Safe for diabetics
Can be used in almost anything

Add Nirvana all-natural yummy Stevia flavours to:

Smoothies
Protein Shakes
Milkshakes
Natural Yoghurt
Breakfast Cereals
Cold Beverages
Spring Water
Coffee and Tea
Desserts
Cocktails
Baking

Certified organic Stevia

The 100% natural Sweetener

All Natural Ingredients

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