Questionnaire for CustomFit Formulations

What are your primary health goals for this formula? (e.g., improve energy, support digestion, balance hormones, manage stress, etc.):

Are there any specific health issues or conditions you would like to address?

Do you have any known allergies? (e.g., foods, herbs, medications, environmental triggers):

Do you have any sensitivities to certain herbs, supplements, or preservatives?

Certain herbs may aggravate digestive conditions like reflux or diarrhea. Are you currently experiencing any digestive concerns such as acid reflux, bloating, diarrhea, or IBS?

Please list all medications you are currently taking, including over-the-counter medications:

Please note the time of day you typically take each medication:

Please list all supplements (e.g., vitamins, minerals, herbs, or nutraceuticals) you are currently using:

Do you have any diagnosed medical conditions? (e.g., thyroid issues, diabetes, cardiovascular concerns, autoimmune diseases):

Are you undergoing any cancer treatments, dialysis, or have kidney disease, or any other medical conditions that may require specific attention when taking supplements?

Have you ever had an adverse reaction to any medication or supplement in the past? If yes, please describe:

Do you follow any specific dietary patterns or restrictions? (e.g., vegan, halal, kosher, gluten-free, dairy-free, etc.):

Do you have any known food intolerances or restrictions? (e.g., gluten, dairy, soy, etc.):

Are you pregnant, trying to conceive, or breastfeeding?

Are you currently scheduled for any surgery? (Certain supplements may need to be discontinued before surgery. Please specify):

Do you consume caffeine, alcohol, or smoke? If so, how much?

Any other relevant information you'd like to share regarding your health, lifestyle, or goals for this formula:

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I consent to the creation of a customised herbal or nutraceutical formula based on this information. I understand that natural medicines may affect individuals differently, and if I experience any adverse reactions, I will immediately stop using the product and contact the naturopath for further guidance. I acknowledge that the information I have provided is for the creation of a personalised herbal or nutraceutical formula. I also understand that herbal and nutraceutical products are not intended to diagnose, treat, or cure diseases, and that the advice provided by the naturopath is not a substitute for medical care or treatment. I have been informed that some of the products may contain alcohol as a preservative and/or bovine collagen, and I have indicated whether or not these ingredients are acceptable for me.