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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)

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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?

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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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Toothpaste (Whitening) Organic Aloe Vera

Dr. Organic

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Description

DR ORGANIC Toothpaste (Whitening) Organic Aloe Vera - 100ml

Ingredients

Glycerin, Aloe Barbadensis Leaf Juice, Sorbitol, Hydrated Silica, Aqua, Sodium Lauroyl Sarcosinate, Mentha Piperita (Peppermint) Oil, Hydroxyethylcellulose, Menthol, Cetraria Islandica (Icelandic Moss) Extract, Sodium Monofluorophosphate, Escin, Xylitol, Sodium Benzoate, Potassium Sorbate, Citric Acid, Limonene. Contains Sodium Monofluorophosphate (A Source of Fluoride at 1000ppm).

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Toothpaste (Whitening) Organic Aloe Vera

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