Questionnaire
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1.  Form for consultation

1. Form for consultation

Name:

Name:


Email

Email


Confirm Email

Confirm Email


What is your birth date?  MM/YR

What is your birth date? MM/YR


Which medications, if any, that you currently take have restrictions?

Which medications, if any, that you currently take have restrictions?


Which herbs, if any, are you currently taking?

Which herbs, if any, are you currently taking?


What is your blood type?

What is your blood type?


Symptoms of a Weak or Toxic Liver

Symptoms of a Weak or Toxic Liver

What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol

What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol


What is your total cholesterol number?

What is your total cholesterol number?


Are you on cholesterol medicine?

Are you on cholesterol medicine?


Have you ever had hepatitis or cirrhosis of the liver?

Have you ever had hepatitis or cirrhosis of the liver?


What is your triglyceride number?

What is your triglyceride number?


Symptoms of a pH imbalance -- acidosis or alkalosis

Symptoms of a pH imbalance -- acidosis or alkalosis

Do you happen to know your saliva and urine pH? If so please put here*

Do you happen to know your saliva and urine pH? If so please put here*


Symptoms of a Glandular Weakness
What is your body temperature (in Fahrenheit )?

What is your body temperature (in Fahrenheit )?


How many moons do you have on the bottom of your fingernail cuticles?

How many moons do you have on the bottom of your fingernail cuticles?


Symptoms of Yeast Overgrowth

Symptoms of Yeast Overgrowth

Symptoms of a Weak Digestion

Symptoms of a Weak Digestion

Symptoms of a Vitamin or Mineral Deficiency

Symptoms of a Vitamin or Mineral Deficiency

Have you every been diagnosed with a disease or health condition? If so please list all.

Are you on any medication which has diet or supplement restrictions?

Are you on a blood thinner?

Are you on SSRI's?

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If you have a discount coupon, please enter coupon # here


How did you learn about Herbal Remedies Expert?

How did you learn about Herbal Remedies Expert?


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Landisville, PA  17538
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