Gut Health Tea Consultation Form.pdf

Gut Health Tea Consultation Form

Please fill out this form to the best of your knowledge to help us create a custom gut health tea tailored to your

needs. Thank you!

Personal Information

Full Name: ___________________________________________________________

Date of Birth: _________________________________________________________

Contact Number: ___________________________________

Email Address: ______________________________________________________________

Address: __________________________________________________________________________________

Medical and Health History

Current Health Status

1. Do you have any existing medical conditions?

Please specify:

_________________________________________________________________________________________________

2. Are you currently taking any medications?

Please list medications and dosages:

_________________________________________________________________________________________________

3. Do you have any allergies?

List all known allergies:

_________________________________________________________________________________________________

Digestive Health Concerns