Health Scan - www.healthscan.co.uk - Gerard Kielty - Food Intolerance

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All correspondence is strictly private and confidential.
If you have any questions about this please contact Mr Gerard Kielty in person by clicking here
This form should take no longer than 5 minutes to complete

Full Name:

Email Address:

Important!

Age Group:

Sex:

Note: This information is totally confidential. It will only be read by Mr. Kielty. Under no circumstances will it be passed to any third party now or in the future.

A 'single' payment of £30 is all you pay - no matter how many boxes you check.

DO YOU SUFFER FROM?:
(Check box where applicable)

Nausea

Epilepsy

Asthma

Sleep Problems

Arthritis

M.E.

Migraine/Headaches

Diarrhoea

Nasal

Constipation

Post Nasal Drip

Bloated Stomach

Irritable Bowel Syndrome

Memory

Hayfever

Mood Swings

Thrush

B.P.

Mouth Ulcers

Eye Sensitivity

Eczema

Heartburn

Itchy Skin

Dermatitis

Irritability

Athletes Foot

Libido

Depression

Hyperactivity

Colitis

Crohns Disease

P.M.T.

Tinitus (Ringing in the ears)

Dizziness

Regular Ear Infections

Lethargy

M.S.

Weight

Concentration

Stress

Catarrh

Loss of confidence

Rhinitis

Coughing

High Blood Pressure

Hot Flushes

Low Blood Pressure

Haemorrhoids

Panic Attacks

Palpitations

Sciatica

Sinusitis

Sneezing

Tourette Syndrome

Colic

Explain here if you are "overweight" or "underweight" and by how much

Please tick the boxes that apply to you:
		Are you/have you taken at any time antibiotics more than once a year on average?
		Do you gag/almost vomit when brushing your teeth?
		Is your blood pressure about normal? If not please TICK BOX and give details in information box below
		Do you suffer from cramp?
		Do you suffer from gout?
		Do you take vitamins daily?
		Do you take minerals daily?
		Do you smoke?
		Do you sweat more than normal?
		Do you have a massage more than once a month? (If so please give details of oils used if possible in the info. box below)
		Do you have any medically diagnosed "allergies"? (If so please specify in information box below)

Further Information: Please provide any further information on your condition which you feel may be relevant.

Do you take on a daily basis: (Check box where applicable)
		Cod liver oil?
		Evening primrose oil?
		Garlic (as a remedy or in food)?
		Non prescribed remedies of any kind? (If so please give full details in further information box above)
		Do you use essential oils on a regular basis?
		Do you drink herbal teas on a regular basis?
		Are you a vegetarian?
		Do you have a sweet tooth?
		Do you cook regularly with herbs and spices?