Follow-Up Form 

Name

Have your symptoms changed since your last consultation Have your symptoms changed since your last consultation Yes No

At what degree have your symptoms improved At what degree have your symptoms improved 1-3 4-7 8-10

At what degree have your symptoms declined At what degree have your symptoms declined 1-3 4-7 8-10

Have you taken your supplements this week as prescribed? Have you taken your supplements this week as prescribed? Yes No

Have you added or changed the dose of any doctor's medication since your last consultation? Have you added or changed the dose of any doctor's medication since your last consultation? Yes No

What medication was added or changed?

Blood pressure (optional)

Weight (optional)

Bowel Motions Bowel Motions Normal Constipation Diarrhoea

Stress levels this week Stress levels this week 0-2 Chilled 3-5 Some stress 6-7 Stressed 8-9 High stress 10 Stressed out

Water per day Water per day 0 litre 1-2 litre 2-3 litres 3+ litres

Coffee per day Coffee per day 0 1 cup per day 2 cups per day 3+ cups per day

Tea per day Tea per day 0 1 cup per day 2 cups per day 3+ cups per day

Alcohol per week Alcohol per week 0 1 standard glass 2-3 standard glasses 3+ standard glasses

Exercise session per week Exercise session per week 0 1-2 2-4 5+

Sleep hours per night, on average Sleep hours per night, on average 3-4 4-5 6-7 8+

General comments about your health