• 2 Evelyn Street, Bairnsdale Vic 3875
03 4108 9313
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Colds and Flus Medical Questionnaire

Natural Medicinal Herbs to Treat Cold & Flu

How it Works

  • Complete the Health Questionnaire below (make sure you complete each section) and submit the information (including payment).
  • One of our practitioners will review your information and then design a herbal formula best suited to you
  • Your herbs will be Express Posted to you.
Patient Information
Are you an existing patient of the clinic?
If you've had an appointment at the clinic before or have purchased herbs from us online before, then you are an existing patient.
Age
Delivery Address
This must be a valid address to which your herbs will be sent via Express Post
Medical Questionnaire
Please let us know why you are ordering?
If you are ordering for a cold or flu you have now, complete the symptoms you have now below. If you are ordering to have the herbs on hand in case you get a cold or flu, complete the symptoms you typically get.
What are your current symptoms? Rate them using the scale below.
Don't haveHave a littleHave moderatelyHave a lotMy main symptom
Body aches
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Cough - dry
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Cough - white or clear phlegm
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Cough - yellow or green phlegm
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Fever
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Chills
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Headache
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Sinus - congestion (blocked nose)
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Sinus - white or clear discharge
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Sinus - green or yellow discharge
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Sinus - hayfever symptoms (sneezing, itchy nose or eyes)
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Throat sore
Don't have
Have a little
Have moderately
Have a lot
My main symptom
Tired
Don't have
Have a little
Have moderately
Have a lot
My main symptom
How do you normally deal with cold & flu?
Do colds normally go to (choose one):
Do you have of these underlying conditions (check all that you have)?
Do you REGULARLY suffer from (tick all that apply)?
Please list all of the medications you are currently taking. If none, please type 'none'.
Please list all. If none, please type 'none'.
Please list all. If none, please type 'none'.
Flavour preference (choose one)
Please provide any other comments you think are relevant for us to consider when designing your tailored herbal formula.
Declarations
One
Two
Three
Four
Five
Preferred method of obtaining your herbs:
How would you like to get your herbs?
For orders placed Monday to Friday by 12pm, your herbs will be Express Posted to you the next day. If you elect to collect from the clinic, we'll call you as soon as your herbs are ready. Note: after you press submit you will be taken to a confirmation page where you can pay for your herbs. Herbs can only be prepared once they are paid for as we tailor them to you.
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