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Symptoms of Food Intolerance

  • Feeling tired, sluggish
  • Haemorrhoids
  • Lethargic
  • Trouble concentrating and Sinus congestion
  • Staying focused
  • Headaches Mood Changes
  • Unusual tingling sensations Back Pain
  • Joint pain Irritability and crankiness
  • Susceptibility to catching Anxiety and anxious feelings
  • Colds & viruses Feeling depressed
  • Trouble sleeping Skin problems
  • Bad breath Allergies
  • Unpleasant body odour
  • Frequent gas, bloating or indigestion
  • Constipation, diarrhoea and other gastrointestinal upset

Skin Care Questionnaire

Please read and answer all of the questions to the best of your ability. It is important to answer honestly.
Health History Questions
YesNo
YesNo
YesNo
YesNo
Cold soresHerpesKeloids
how often?Last breakout?Area of breakout?
YesNo

YesNo

MicrodermabrasionChemical peelCollagenBotox

Anti-agingNormal/DryOily/CombinationSensitiveAcneOther
I have answered all questions to the best of my ability, all of my known medical conditions. I agree to keep my Arbonne Independent Consultant updated as to any changes in my medical profile and understand that there shall be no liability if I fail to inform them of any changes.

Do I need a body cleanse?

Just like dusting your furniture and cleaning your bathrooms, the human body needs to be cleaned too. Especially if you have a diet that includes packaged foods, hydrogenated fats and oils, white flour and sugar or if you are exposed to:

  • Second-hand smoke Fertilizers Garden pesticides
  • Vehicle Fumes Dust Mould
  • Mildew Animal Dander Electrical devices
  • Household Cleaners Photocopiers Pollution
  • Smog Smoke Heavy metals
  • Paint Fumes Dry cleaned clothing Rain

My checklist to signal it may be time for a reliable Body Cleaning

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you answered yes to three or more of the above questions, it may be time to reset

Confidential Questionnaire

This information on this questionnaire is strictly confidential.

SingleMarriedDivorced
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Thrush Cystitis PMSEczema Dermatitis Muscular Aches / PainsCramp Swelling High Blood PressureArthritis Asthma Low Blood PressureDepression Insomnia Cold hands / feetAnxiety Nausea Pain (anywhere)Exhaustion Mood Swings Generally feeling unwellIndigestion Bloating Migraine / HeadacheExcess Wind Diarrhoea Difficulty concentratingConstipation Incontinence Fluctuating weight
DailyWeeklyNeverBiscuitsCakeChocolate / sweetsBreadMeatFishCheeseEggsNutsMilkFizzy DrinksFruitFruit JuiceVegetablesSugarAlcoholCigarettes
WaterTeaCoffee
I understand that I am responsible for my own health and that any recommendations I receive are not intended as a replacement for medical interventions and advice from my G.P or consultant.
I agree to advise all medications and supplements that I take and any new diagnosis or treatment.