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Submit Your Health Questionnaire

Give us the facts, and we will give you a way forward. This questionnaire is your first step toward clarity. Answer every question to the best of your ability. We will personally review your responses and deliver tailored recommendations.

First name

Last name

Email

How old are you?

Which of the following areas are you most interested in getting help with? (Please tick all that apply)

Lab Test Advice (e.g., which test would be most suitable for me)

Dietary Advice (e.g., what foods to eat/avoid, meal ideas)

Supplement Recommendations (e.g., which specific supplements could help me)

Lifestyle Changes (e.g., sleep, stress management, exercise advice)

Have you seen a practitioner or had lab tests for this issue in the past? If yes, please briefly describe.

Have you been diagnosed with any of the following?

IBS (Irritable Bowel Syndrome)

SIBO (Small Intestinal Bacterial Overgrowth)

Coeliac Disease

Inflammatory Bowel Disease (Crohn's, Colitis)

For those who menstruate: Are your cycles regular? If not, please describe.

Do you experience any of the following?

Do you suffer with autoimmune, if yes, please provide details

How many pints of plain water do you drink per day?

What do you have for breakfast typically each day?

What do you have for lunch typically each day?

What do you have for dinner typically each day?

What snacks do you have typically each day?

Do you drink coffee? If yes, how much? Caffeinated or decaf?

Do you drink alcohol? If yes, how frequently?

If you are on birth control or HRT, how long for?

Under 1 year

1-5 years

5 years+

Do you exercise? If yes, what type and how often?

Please list any medications you are currently taking.

Please list any supplements you are currently taking.

Have you been diagnosed with a condition?

Is there anything else you think I should know about your health or lifestyle?

I understand that this questionnaire and any guidance provided is for informational purposes only and does not constitute medical advice, diagnosis, or treatment.

It is not intended to replace consultation with qualified healthcare professionals or my GP. I will always seek the advice of my doctor or other qualified health provider with any questions I may have regarding a medical condition.

Do you have questions?

Email

info@nutritionoutlaw.com