Pre-consultation Questionnaire - Advanced Natural Medicine

Name*

First Last

Email*

Phone*

1. Would you like to increase your ENERGY levels or check they are optimal?*

2. Would you like to decrease your chances of becoming ill?*

3. Do you wish to know whether you're getting the nutrition your body requires?*

4. Do you want to ensure that your mental alertness and concentration are optimal?*

5. Do you want to increase your sports stamina and performance?*

6. Do you suffer from any medical condition or illness?*

Please specify which medical condition or illness you suffer from.

7. Do you want to increase your libido?*

8. Would you like to lose weight?*

9. Do you suffer from constipation, bloating, loose bowels, stomach pain/discomfort or acid reflux?*

10. Would you like us to contact you for a free 10 minute health discussion? (within Auckland area only)*

Online Questionnaire