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Medical Questionnaire

Home
About
Shop
FAQS
Medical Questionnaire

Lets get to know you

Complete this short medical questionnaire to help determine if B12 treatment is suitable for you

Full Name*

Date of Birth*

Email Address*

Address Line 1*

Postcode*

Town or City*

County*

Allergies*

Are you receiving any treatment from a doctor or specialist? *

Yes

No

If Yes: What treatment are you receiving?

Are you taking any medications or herbal remedies? (e.g., antibiotics, muscle relaxants, St. John’s Wort, etc*

Yes

No

If Yes: List them here

Have you been diagnosed with any medical conditions?*

Yes

No

If Yes: Please list them here

Are you a strict vegetarian or vegan?*

Yes

No

Do you drink alcohol regularly? *

Yes

No

Do you suffer from fatigue or weakness? *

Yes

No

Do you feel low or experience mood swings? *

Yes

No

Do you experience tingling or numbness in your hands or feet?*

Yes

No

Is your skin often pale?*

Yes

No

Contact

Email: b12boost@mail.com

Tel: 07459190291

Your Email

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