The Terracotta Cottage  Health Questionnaire
 
If you have any question, on your general health and/or supplements, you can contact our in house health practitioner by completing the form below.
 
It will help us to provide a better answer if you include what medications and supplement you are currently on, and the history of your health.
 The Terracotta Cottage
 
*First Name
*Last Name
*Email
*Address 1
Address 2
*City
*State
Post Code/ZIP
*Country
*Phone
*Date of Birth
*Male or Female
*Please outline your main heath concerns
*How long have you had these health concerns
*Does anything make you health concerns worse?
*Does anything make your health concerns better?
*Please provide details of any other existing health conditions
*Please provide details of any health conditions you have had in the past
*Please list any medication you are taking
*Please list any supplements, herbal medicine, homoeopathics, vitamins or minerals you are taking
*Do you have any allergies or sensitivities?
*Please provide details of what you would normally have for breakfast
*Please provide details of what you would normally have for morning tea
*Please provide details of what you would normally have for lunch
*Please provide details of what you would normally have for afternoon tea
*Please provide details of what you would normally have for dinner
*Please provide details of what you would normally have for after dinner
*How many cups/glasses of tea or coffee/water do you drink daily? Please list each one separately
*How many cups/glasses of alcohol do you drink daily? And what type, beer, wine or spirits?
*Do you smoke and if so how many cigarettes per day?
*Females only, are you pregnant or breast feeding

 
PRIVACY DISCLOSURE The personal information you have provided is being collected by The Terracotta Cottage  for the purpose of providing  advice to you and suggesting vitamins and supplements which may assist you. In this process, we may also collect certain sensitive information from you including details regarding your medical history, your history of therapeutic goods use and your health issues. We understand that in providing such sensitive information that you consent to us collecting that information for this purpose.

If you do not provide the information requested, we will be unable to assist you with your inquiry and to provide you with accurate advice and recommendations.
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