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Colds and Flus Medical Questionnaire

An Antibiotic Alternative

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

Patient Information

Full Name *

Email Address *

Are you an existing patient of the clinic? *

I am already a patient
I am not yet a patient

If you've had an appointment at the clinic before or have purchased herbs from us online before, then you are an existing patient.

Your Weight (in kilograms) *

Date of Birth *

Gender *

Age *

Adult (over 18)
Child (3-18)
Infant (under 3)

Phone Number *

Delivery Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

This must be a valid address to which your herbs will be sent via Express Post

Medical Questionnaire

Medical Questionnaire

Please let us know why you are ordering? *

I am ordering for a cold or flu I have now
I am ordering to have the herbs on hand if I get a cold or flu

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 have	Have a little	Have moderately	Have a lot	My main symptom
Body aches	Don't haveBody aches Don't have	Have a littleBody aches Have a little	Have moderatelyBody aches Have moderately	Have a lotBody aches Have a lot	My main symptomBody aches My main symptom
Cough - dry	Don't haveCough - dry Don't have	Have a littleCough - dry Have a little	Have moderatelyCough - dry Have moderately	Have a lotCough - dry Have a lot	My main symptomCough - dry My main symptom
Cough - white or clear phlegm	Don't haveCough - white or clear phlegm Don't have	Have a littleCough - white or clear phlegm Have a little	Have moderatelyCough - white or clear phlegm Have moderately	Have a lotCough - white or clear phlegm Have a lot	My main symptomCough - white or clear phlegm My main symptom
Cough - yellow or green phlegm	Don't haveCough - yellow or green phlegm Don't have	Have a littleCough - yellow or green phlegm Have a little	Have moderatelyCough - yellow or green phlegm Have moderately	Have a lotCough - yellow or green phlegm Have a lot	My main symptomCough - yellow or green phlegm My main symptom
Fever	Don't haveFever Don't have	Have a littleFever Have a little	Have moderatelyFever Have moderately	Have a lotFever Have a lot	My main symptomFever My main symptom
Chills	Don't haveChills Don't have	Have a littleChills Have a little	Have moderatelyChills Have moderately	Have a lotChills Have a lot	My main symptomChills My main symptom
Headache	Don't haveHeadache Don't have	Have a littleHeadache Have a little	Have moderatelyHeadache Have moderately	Have a lotHeadache Have a lot	My main symptomHeadache My main symptom
Sinus - congestion (blocked nose)	Don't haveSinus - congestion (blocked nose) Don't have	Have a littleSinus - congestion (blocked nose) Have a little	Have moderatelySinus - congestion (blocked nose) Have moderately	Have a lotSinus - congestion (blocked nose) Have a lot	My main symptomSinus - congestion (blocked nose) My main symptom
Sinus - white or clear discharge	Don't haveSinus - white or clear discharge Don't have	Have a littleSinus - white or clear discharge Have a little	Have moderatelySinus - white or clear discharge Have moderately	Have a lotSinus - white or clear discharge Have a lot	My main symptomSinus - white or clear discharge My main symptom
Sinus - green or yellow discharge	Don't haveSinus - green or yellow discharge Don't have	Have a littleSinus - green or yellow discharge Have a little	Have moderatelySinus - green or yellow discharge Have moderately	Have a lotSinus - green or yellow discharge Have a lot	My main symptomSinus - green or yellow discharge My main symptom
Sinus - hayfever symptoms (sneezing, itchy nose or eyes)	Don't haveSinus - hayfever symptoms (sneezing, itchy nose or eyes) Don't have	Have a littleSinus - hayfever symptoms (sneezing, itchy nose or eyes) Have a little	Have moderatelySinus - hayfever symptoms (sneezing, itchy nose or eyes) Have moderately	Have a lotSinus - hayfever symptoms (sneezing, itchy nose or eyes) Have a lot	My main symptomSinus - hayfever symptoms (sneezing, itchy nose or eyes) My main symptom
Throat sore	Don't haveThroat sore Don't have	Have a littleThroat sore Have a little	Have moderatelyThroat sore Have moderately	Have a lotThroat sore Have a lot	My main symptomThroat sore My main symptom
Tired	Don't haveTired Don't have	Have a littleTired Have a little	Have moderatelyTired Have moderately	Have a lotTired Have a lot	My main symptomTired My main symptom

List any other symptoms not already covered above (if applicable)

How do you normally deal with cold & flu? *

I usually get over it quickly
It usually takes me a while to get over it

Do colds normally go to (choose one): *

Your chest
Your sinuses
Both your chest and sinuses
Neither

Do you REGULARLY suffer from (tick all that apply)? *

Reflux/indigestion
Loose bowels/diarrhoea
Upset stomach
None of these

Current medications *

Please list all of the medications you are currently taking. If none, please type 'none'.

What other underlying conditions do you have (other diseases or health problems)? *

Please list all. If none, please type 'none'.

Please list all allergies *

Please list all. If none, please type 'none'.

Flavour preference (choose one) *

I want a liquorice flavour (makes the herbs sweeter) added to my herbs
I do not want a liquorice flavour added to the herbs (you can always add some juice to your herbs instead)

Any other comments?

Please provide any other comments you think are relevant for us to consider when designing your tailored herbal formula.

Declarations

Please read and agree to all

One *

The herbal formula will be tailored for me based on the information I have supplied on this form

Two *

The herbs are in liquid form and don’t taste very nice (but you can take them with juice)

Three *

The herbs are in a food-grade ethanol base (which is used to extract the effective compounds from the natural herbs and keep them fresh)

Four *

The herbs supplied is for a 5 day course of treatment to help you get on top of your cold/flu

Five *

The herbs are medicinal strength, however there is no guarantee (with any herbs or medicines you take) that you will be cured within the 5 days (but they usually are very effective for the majority of people)

Preferred method of obtaining your herbs:

Getting your herbs

How would you like to get your herbs? *

Express Posted (herbs $85, Postage $15) - $100.00
Collect from the clinic - $85.00

For orders placed Monday to Friday by 12pm, your herbs will be Express Posted to you that day. For orders placed after 12pm or on a weekend or public holiday, your herbs will be Express Posted to you the next business day. If you elect to collect from the clinic, we'll call you as soon as your herbs are ready.

Payment

Payment

Stripe Credit Card *

Total

$0.00

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.

Evergreen Natural Health - Bairnsdale

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