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In Nature Teas
Pure High Grade Organic Teas




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Free Health Consultation

Available with any purchase of our high grade loose teas

Personal Profile - Private and confidential

Please complete the questions and rest assured that all the answers will be treated with the UTMOST CONFIDENTIALITY. None of the information will ever be transferred or communicated to a third party.

Your details will be sent to our resident doctor who will evaluate your condition. Our doctors has many years of experience dealing with various conditions through Traditional Chinese medicine. This traditional approach is 100% natural, without any use of chemicals or artificial drugs.

If we believe that your condition cannot be treated with on line diagnosis and support then we will suggest you contact a local medical practicioner.

Our objective is to follow the three principles of good health which are:

• good food
• good physical activity
• good sleep

We may also recommend a little daily meditation to improve the state of the mind and the spirit.

 

Personal details

1) First name
2) Second name [OPTIONAL]
3) Email address
4) Address [OPTIONAL]
5) phone number [OPTIONAL]

Health questionnaire

1) Gender
2) Age
3) What's your total yearly income before tax?
4) What's your marital status?
5) What's your employment status?
6) Your height
7) Your weight
8) Please rate your general health on the scale below
Poor
Excellent
9) Would you like to see an improvement with regard to any of the following?
Weight
Depression
Skin condition
Heart problems
Kidney malfunction
Blood circulation
High blood pressure
Eyes
Digestion
Insomnia
Stress
Eating disorders
Fatigue
Other
10) Please rate your appetite on the scale below
Poor
Excellent
11) Please describe your basic diet
Breakfast:

Lunch:

Supper
12) Do you eat snacks or junk food between meals?
Yes      No
13) How often do you drink alcohol?
14) Do you drink coffee?
15) Do you drink tea?
16) If you drink tea, how often do you drink it?
17) How are your bowels?
18) Passing water?
Poor
Fair
Good
19) How is your sleep?
Poor
Fair
Good
20) Where do you exercise?
21) Do you do any physical activities?
22) How often do you exercise?
23) What is your blood pressure?
24) Have you had any operations? (if yes, give details)
Yes      No
25) Do you smoke?
How many cigarettes a day?
26) Is there a history of any of the following in your family?
Diabetes
High blood pressure
Cancer
Genetic diseases
None of the above
27) [Women only] Do you suffer from any of the following?
Irregular menstrual cycle
Infertility
Repeated miscarrriage
Anaemia
Menopausal symptoms (hot flushes, irritability, memory loss)
Cysts
Fibroids
None of the above
28) [Men only] Do you suffer from any of the following?
Premature ejaculation
Impotence
Prostatitis
Reduced sexual performance
Loss of libido
None of the above
29) Do you suffer from any of the following?
Eczma
Hayfever
Herpes
Psoriasis
Acne
Hair loss
Prurigo
Athlete's foot
Fungal infections
Abscess
Eniarged
Cystitis
Gallstones
High Cholesterol
Hepatitis
Memory loss
Dermatitis
Vitiligo
Bronchitis
Bad breath
Pharyngitis
Arthritis
Palpitations
Back pain
Diabetes
None of the above
30) Do you suffer from any unusual ailment not covered here? (please describe)
31) Have you been diagnosed with a terminal illness?
Yes      No
32) Please provide a brief summary of your medical history
33) Please tell us about any medication you are currently taking
34) Do you have a satisfactory sex life?
Yes      No
35) Have you ever tried traditional chinese medicine?
Yes      No
36) If yes, how long have you been practicing traditional chinese medicine?
36) If yes, how often do you visit the traditional chinese medicine doctor?

Optional section

1) Tell us about your main health problem
2) What do you believe would be the way to better health for you?
3) What are the main areas of weakness in your health that you would most like to address?
4) What would you most like to change about your body (list as many things as you like)?
5) Would you say you were happy with life at the moment? If not, why not?
6) If you have been unable to get satisfactory treatment from your GP, have you tried alternative solutions such as chinese medicine?
7) How did you find the In-Nature web site?

Please feel free to give as much detail as you want. It will help us form a better picture of your overall condition.
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