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Health Questionnaire

Please give as much information as possible as this will allow me to adjust your protocol and be aware of any pitfalls you may have.


Be sure to mention if you have any of the following:
Blood pressure problems
Heart/Stroke/TIA/Palpitations problems

Circulatory problems  – legs/arms/hands

Varicose veins

Ankle swelling

Lung/Breathing problems

Chest pains

Cold sweats

Diabetes/Endocrine problems

Digestive problems

Irritable Bowel Syndrome (IBS)

Acid reflux

Bowel problems

Bladder/Kidney problem/Prostrate
/urination problems

Reproductive problems

Cancer

Skin Disorder

Allergies

Hearing problems

Jaw pain/clicking/grinding/teeth removed

Migraine/Headaches

Dizziness

Loss of balance

Loss of consciousness

Loss of taste/smell/vision

Tinnitus (buzzing in the ear)

Sleeping problems/Tiredness

Eyes/Ears/Nose/Throat/Sinus problems

Multiple Sclerosis

Parkinson’s Disease

Other neurological disease

ME/Chronic Fatigue

Epilepsy/Fits

Anxiety/Stress

Depression /No

Psychiatric/Mental Disorder

Arthritis/Orthopaedic problems

Joint swelling

Numbness

Pins & Needles

Unintentional weight gain or loss

Poor immunity

Any other problems

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