Full Name *

Date of birth *

Gender *

Male

Female

Other

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

Height

Metric or imperial system accepted.

Weight

Enter weight in kg or lbs.

Is this your first assessment or a follow-up?

First assessment

Follow-up assessment

Have you used cellular focused botanical based supplements before?

Yes

Do you consent to the use of Glandular medicines (derived from bovine tissues) in your program?

Yes

If you're unsure of any reading below, write 'not sure'.

Blood pressure & resting pulse (right arm)

SYS/DIA/HR - Any pharmacy can complete these readings if you don't have your own BP machine.

Blood pressure & resting pulse (left arm)

SYS/DIA/HR - Any pharmacy can complete these readings if you don't have your own BP machine.

Right basal temp (axial)

Deg C or F - Use a probe style thermometer and take a reading from the armpit.

Left basal temp (axial)

Deg C or F - Use a probe style thermometer and take a reading from the armpit.

Urine pH (am)

Use a pH testing strip to take a reading and record the result.

Saliva pH (am)

Use a pH testing strip to take a reading and record the result.

How many bowel movements do you have per day?

If not daily, please disclose current frequency.

Your liver status is:

Do you have iron dysregulation?

Yes

Select 'Yes' if low or high iron levels, anemia, or taking an iron supplement on medical advice.

If you have the following data available, please enter your marker levels below:

Serum Iron (umol/L)

Serum Ferritin (ug/L)

Transferrin (umol/L)

Transferrin Saturation %

Do you take Vitamin D supplements regularly?

Yes

Do you take Vitamin C supplements regularly?

Yes

Please list any pharmaceutical medications you are currently taking, including the condition or symptom each was prescribed for. Also include any chemotherapy, radiation, antibiotics, cortisone, or anaesthetic treatments received in the past 24 months.

Medication name and reason for taking.

Are you currently taking any herbal products or supplements? If yes, please list them individually below.

Please list the name of herbal product and reason for taking.

What does your daily diet currently consist of?

What food groups do you typically consume throughout the day?.

What are your primary health concerns?

What issue(s) cause you the most pain or dysfunction?

Do you have any other health concerns aside from your primary issue?

Yes

The following questions capture important information about your current and past health. Your answers allow us to build an effective, personalised program for you.

Check only the conditions you have had or are currently experiencing. If a condition doesn't apply to you, leave it blank.

Please answer as thoroughly as possible.

What do you hope to gain from this program?

What are your intentions after completing this program?

After completing this program, do you plan to return to your previous habits, continue applying what you've learned, or push toward higher goals? Please explain your thinking.

Please list any known health conditions, illnesses, or causes of death for each family member. If unknown, leave blank.

Mother

Father

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Siblings

Children

Previous Surgical Procedures

Do you have cold hands or feet?

Current

Past

Comes & goes

Do you feel cold externally but hot or burning internally?

Current

Past

Comes & goes

Do you find it easy to gain weight but hard to lose it?

Current

Past

Comes & goes

Do you suffer from headaches or migraines?

Current

Past

Comes & goes

Are you easily irritated by things?

Current

Past

Comes & goes

Are you currently overweight or have you struggled with your weight?

Current

Past

Comes & goes

Do you experience low energy or persistent fatigue?

Current

Past

Comes & goes

Does a member of your immediate family have, or have they had any of the following

Goiter

Hashimoto's

Grave's Disease

Reidel's Disease

How much do you sweat when resting?

Nil

Light Perspiration

Gushing

How much do you sweat when exercising?

Nil

Light Perspiration

Gushing

Are your fingernails (check all applicable)

Ridged

Brittle

Weak

No functioning quick

Do you have (check all applicable)

Varicose Veins

Spider Veins

Do you have (check all applicable)

Hemorrhoids

Prolapses

Herniations

Aneurysm

Do you suffer muscle cramping?

Current

Past

Comes & goes

Would you consider your bladder

Strong

Leaks occasionally

Weak

Have you been medically/pathologically scored with

Low Bone Density

Low Calcium

Do you bruise easily?

Current

Past

Comes & goes

Do you identify with any mental health challenges?

Depression, anxiety PTSD, OCD, etc. Please describe.

Slow or sluggish digestion?

Current

Past

Comes & goes

High bowel transits (diarrhoea)

Current

Past

Comes & goes

Do you notice undigested food in your stool

Current

Past

Comes & goes

Acid reflux, indigestion or heartburn?

Current

Past

Comes & goes

Are you thin and/or have trouble gaining weight?

Current

Past

Comes & goes

Are moles present on your body?

Current

Past

Comes & goes

Do you have (check all that apply)

ALS

Parkinson's

Palsy

Do you experience excessive shyness/inferiority complex?

Current

Past

Comes & goes

Do you experience tremors or nervous legs?

Current

Past

Comes & goes

Do you have high blood pressure?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have low blood pressure?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have hypoglycemia (low blood sugar)?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Have you been diagnosed with diabetes?

Yes

Do you experience tinnitus (ringing in the ears)?

Current

Past

Comes & goes

Do you have difficulty taking deep breaths?

Current

Past

Comes & goes

Do you find you are often short of breath?

Current

Past

Comes & goes

Do you have any cardiac arrythmia?

if so, please detail which type

Do you have any challenges getting to sleep?

Current

Past

Comes & goes

Do you have any challenges staying asleep?

Current

Past

Comes & goes

Do you have

Addison's disease

Congenital adrenal hyperplasia

Have you been diagnosed with high cholesterol?

Current

Past

Comes & goes

Do you have any “itis” conditions (arthritis, osteoarthritis, bursitis, etc.)?

Yes

Have you been diagnosed with

ADD

ADHD

Autism

N/A

Bowel Movements

Less than 1 every 3-4 days

1 every other day

1-3 per day

4+ per day

Do your bowel movements leave you feeling

Satisfied

Screaming for an encore

Unsure about the effectiveness

Do you have Gastroparesis (paralysis of the stomach)?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have a coated tongue, especially upon waking?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have gas problems?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have bloating problems?

Current (medicated)

Current (unmedicated)

Past

Comes & goes

Do you have any other GI issue not discussed in this section?

Is your hair

Thinning

Balding

Fully Bald (not by choice)

Have you had lymph nodes removed?

Yes

How often do you get cold & flu-like symptoms?

Do you smoke?

Yes

Past

If you are not female, please skip to section 12B.

Are you currently pregnant?

Yes

Are you currently breastfeeding?

Yes

Irregular menses

Current

Past

N/A

Excessive bleeding during menstruation

Current

Past

N/A

Reproductive System: Do you have (or have you had)

Do you rate your libido

Low

Excessive

Swings between low & excessive

Have you had a hysterectomy?

Yes

Any difficulty experienced conceiving?

Current

Past

Please detail anything else related to this section that hasn't been covered

If you are not male, please skip to section 13.

Do you consider your libido

Low

Excessive

Swings between low & excessive

Vaccinations Received

Standard Australian schedule

International schedule

COVID-19

Annual flu shot

Do you have a water filter in your home?

Yes

Do you live in an agricultural community?

Yes

Have you used any recreational or performance enhancing drugs?

Yes

I confirm that I have reviewed and completed all fields in this form before submitting. *

I have completed all fields in full.