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Health Questionnaire

 

In order for us to give you an accurate assessment of your hair sample it is critical that you fill in this health questionnaire as, without it, we can NOT complete the report process. Please fill in your details below and choose 5 most predominant symptoms/conditions that you suffer from.

If you missed the previous 4 steps necessary to complete your 5 step order, see All steps involved.

Health Questionnaire

    Your full name (required):

    Your Email (required):

    Country:

    Address:

    Suburb:

    State:

    Occupation:

    Post Code:

    Telephone:

    Mobile no:

    Date of Birth:

    Sex: MaleFemale

    Pregnant: YesNoNot Applicable

    Height(in cm): Weight(in kg):

    Current Medications:

    Shampoo:StandardDandruff Treatment

    Hair Sample Location:

    Natural Hair Colour: Hair Treatment:

    Muscle & Bone: Heart & Blood:

    Intestinal Area: Kidney:

    Neurological: Emotional:

    Male problems: Female problems:

    Other:

    Cancer:

    Reason for Test & Details of Last 2 Vaccinations (Year & Type):

    I am ordering the Hair Mineral and Heavy Metal Test and Reports (Profile 2)

    Please Note: a 20% administration fee is applicable upon cancellation prior to laboratory work.Once Laboratory work starts no refunds.

    Please mail your hair sample to: Hair Sample Testing, Attention Dr Voula Roumel, Brunswick Health Clinic 68 Melville Road Brunswick West Vic 3055 Australia

     

     

     

    Click to order your hair mineral & toxic metal test

     

     

     

    Have you completed the 5 necessary steps to complete your order?