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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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Sublingual B12 1000mcg Tablets

Eagle

EPSUB12

As low as $25.93

Qty

- +

SUBLINGUAL B12 1000 is for the maintenance of vitamin B12 levels in the body, particularly required for vegetarians, vegans, and the elderly. Vitamin B12 aids in healthy red blood cell production supports nerve conduction, helps convert carbohydrates, proteins, and fats into energy, and supports general health and well-being.

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Sublingual B12 is an effective and convenient form of administration.

Assists healthy red blood cell production
Maintains red blood cell health
Supports nerve conduction
Supports energy production
Assists glucose/carbohydrate metabolism
Improves and helps maintain vitamin B12 levels in the body

Each sublingual berry flavoured tablet contains:
Cyanocobalamin (Vit. B12) 1 mg

ADULTS: Dissolve 1 tablet under the tongue daily.

Or as directed by your healthcare professional.

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