Name *

First Name

Last Name

Symptoms *

Are you, or have you been, exposed to insecticides, pesticides or herbicides in the last 12 months (e.g. had your home sprayed for pests, or used weed killing sprays, termite or flea treatments)?

Are you, or have you been, exposed to heavy traffic, exhaust fumes and pollution?

Do you use synthetic cleaning products at home (e.g. disinfectants, detergents, bleach, polishes and similar products)?

Do you consume food or drink from plastic, plastic-lined containers, tin or aluminum? (e.g. bottled water, disposable coffee cups, canned food, aluminum cans, takeaway food containers)?

Do you want to make changes for healthier eating?

Do you eat processed foods? Foods with additives?

Do you drink most days or more than 4 alcoholic drinks in one sitting?

Do you suffer fatigue?

Do you suffer headaches?

Do you have skin outbreaks/issues?

Have you lost/are you trying to lose a significant amount of weight?

Do you have gastrointestinal symptoms?

Do you take pharmaceutical anti-inflammatory or pain relief medicines?

Have you been on antibiotics in the past 12 months?

Have you done a Practitioner guided detoxification in the past year?

Do health complaints reappear or worsen during weight loss?

Are you irritable all the time?

Are you waking often in the night? overheating?