Medical Intake Form

Please note that filling out the form below is required to proceed. We kindly ask that you provide accurate and complete information to ensure a smooth and efficient processing of your request.

Detailed Medical Intake Form

    IBS/IBDBloatingGas/FlatulenceAcidity/Acid Reflux/GERDLactose IntoleranceFood Sensitivities /AllergiesH-Pylori other infectionsGall Stones & Kidney StonesC-leveled EnzymesFatty Liver

    Insulin - Insulin ResistanceThyroid (Hyper & Hypo)Estrogen - Estrogen Dominance/PCOSCortisol - Stress/Anxiety DepressionMenopause/ Menstruation ProblemsFibroids

    Rheumatoid ArthritisHashimoto's ThyroiditisLUPUSDiabetesAcneAsthmaPsoriasisRosaceaEczemaBronchitisSleep ApneaSinusitis TinnitusOther

    OsteoporosisArthiritsCervical SpondylitisBackpainStiffnessKnee PainAise Herniation/Prolapse Slip Disc

    High Blood Pressure HypertensionHigh cholesterol/TriglyceridesPot Belly/Belly FatStubborn Weight GainIncreased WaistilineHigh Uric Acid

    CancerParkinsonAlzheimerHeart Disease

    Disturbed sleepHigh StressLow Energy LevelsConstant Brain Fog/Focus IssuesMemory Loss

    Weight-Gain/Inch-LossDull PigmentationDry Flaky SkinAging SkinHairfall/HairlossBrittle NailsBelly Fat/ Thigh/ Arm Fat