The Terracotta Cottage  Weight Management
If you would like some assistance with a weight management problem, you can complete this questionnaire which will be answered by our in house health practitioner
The Terracotta Cottage

 

*First Name
*Last Name
*Email
*Address 1
Address 2
*City
*State
Post Code/ZIP
*Country
*Phone
*Your weight in kilograms
*Your height in centimetres
*Male or Female
*If Female are you pregnant or breastfeeding?
*Date of Birth
*Have you had any disorders or illnesses in the past 10 years. Please list
*Do you have at present any disorders or illness. Please list
*Are you taking any medication. Please list
*Are you taking any herbs, homoeopathics, nutritional supplements or other alternative medicines Please list
*Do you play any regular sport. Please list
*Do you do any regular exercise, walking; gym; etc. Please list
*Do you smoke and how many cigarettes per day?
*Do you drink alcohol How many glasses per week and what type? wine, beer, spirits?
*Do you have a bowel movement every day?
*If no How often do you have a bowel movement?
*How much water do you drink in one day?
*Do you have a goal or target weight that you are aiming for?
*Do you have any disabilities that may interfer with an exercise programme?
*Do you have a support group or friends and family that will encourgage you through this programme?
*Is there any other inforamtion you would like to provide?
*Please answer yes or no to:- I state the above information it true and correct

 
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
Website Software by Aqua Websites