Name *

First Name

Last Name

Select the areas you have concerns with

Headaches / Migraines

Hair Loss / Dandruff

Circulation - cold extremities

Heat / Sweating

High Blood Pressure

Low Blood Pressure

Lungs - breathless / asthma /emphysema

Upper Digestion - heartburn / belching / bad breath/

Lower Digestion - gas / pain or itching / constipation / diarrhoea

Skin - rosacea / hives / rashes / acne

Joint pain / inflammation

Reproduction - fertility /menstrual cycle / menopausal symptoms

Hormonal Imbalances - Diabetes / Thyroid / Weight Metabolism

Mood Swings - anger / irritability / depression

What are your stress levels like?

Through the roof most days

I can be reactive if something unexpected happens and it takes me a while to regulate.

Low level background stress consistent most of the day

I know how to self regulate

I'm pretty relaxed most of the time

Relationship with sugar

How many of the following do you consume regularly (more than 3 times a week)?

add sugar to hot drinks

soda / cordial

fruit juice

alcohol (more than 14 units per week)

sweets or milk chocolate

biscuits / cakes

white flour products (pasta/ bread / wraps / croissants)

fried potatoes / crisps / chips

short grain rice or sticky rice

Hunger

Do you ever get "Hangry" - reach intense levels of hunger and can't concentrate on anything until you've eaten?

Yes, frequently

Sometimes

Rarely