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BEFORE YOUR
CONSULT
This will help us gain insights to your health before our first consultation.
Name
Email
Phone
Rate each of the following symptoms based upon your health profile for the past 30 days
Point Scale
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Nausea or Vomiting
Nausea or Vomiting
0
1
2
3
4
Diarrhoea
Diarrhoea
0
1
2
3
4
Constipation
Constipation
0
1
2
3
4
Bloated Feeling
Bloated Feeling
0
1
2
3
4
Belching or Passing Gas
Belching or Passing Gas
0
1
2
3
4
Heartburn
Heartburn
0
1
2
3
4
Rate each of the following symptoms based upon your health profile for the past 30 days
Point Scale
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Itchy Ears
Itchy Ears
0
1
2
3
4
Earaches, Ear Infections
Earaches, Ear Infections
0
1
2
3
4
Drainage from Ear
Drainage from Ear
0
1
2
3
4
Ringing in Ears, Hearing Loss
Ringing in Ears, Hearing Loss
0
1
2
3
4
Mood Swings
Mood Swings
0
1
2
3
4
Anxiety, Fear of Nervousness
Anxiety, Fear of Nervousness
0
1
2
3
4
Anger, Irritability or Aggressiveness
Anger, Irritability or Aggressiveness
0
1
2
3
4
Depression
Depression
0
1
2
3
4
Fatigue, Sluggishness
Fatigue, Sluggishness
0
1
2
3
4
Apathy, Lethargy
Apathy, Lethargy
0
1
2
3
4
Hyperactivity
Hyperactivity
0
1
2
3
4
Restlessness
Restlessness
0
1
2
3
4
Watery or Itchy Eyes
Watery or Itchy Eyes
0
1
2
3
4
Swollen, Reddened or Sticky Eyelids
Swollen, Reddened or Sticky Eyelids
0
1
2
3
4
Bags or Dark Circles under Eyes
Bags or Dark Circles under Eyes
0
1
2
3
4
Blurred or Tunnel Vision
Blurred or Tunnel Vision
0
1
2
3
4
Headaches
Headaches
0
1
2
3
4
Faintness
Faintness
0
1
2
3
4
Dizziness
Dizziness
0
1
2
3
4
Insomnia
Insomnia
0
1
2
3
4
Irregular or Skipped Heartbeat
Irregular or Skipped Heartbeat
0
1
2
3
4
Rapid or Pounding Heartbeat
Rapid or Pounding Heartbeat
0
1
2
3
4
Chest Pain
Your Results, Along with your Vital Health score will be emailed to you.
Your Total Result
total result
Send Me My Results
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