HEALTH QUESTIONNAIRE

This Consultation Form will assist your practitioner in preparing advice about Regul8®.

Please read the label of Regul8® and all dietary supplements before usage and consult your healthcare professional.

Please answer yes or no if you suffer from the following and give a rating of 0 to 10 on the severity.

0 being none, 5 indicates moderate, 10 indicates all the time.

Allergies may be an indication of compromised digestive health.

These are clues that indicate you are not digesting your food thoroughly, and the resulting immune reaction in your intestines is inflaming the delicate gut lining

If skin on the outside of your body is inflamed, it may be indication that your skin on the inside is also inflamed.

If skin on the outside of your body is inflamed, it may be indication that your skin on the inside is also inflamed.

Average Daily Diet:

Sleep

Mood Disorders

Harmful bugs in your intestines produce toxins that may travel right through your bloodstream and they may cross through your blood brain barrier. These toxins may disrupt the production of neurotransmitters in your brain and negatively affect your mood.

There is research to link between autoimmune disease and leaky gut syndrome. There are 81 recognised autoimmune diseases; the most common ones are Hashimoto’s thyroiditis, rheumatoid arthritis and psoriasis.

This may be a symptom of an inflamed gut. Toxins that enter the bloodstream through the gut lining typically lodge in the joints and create pain and inflammation.

CONTRAINDICATIONS

CONSENT

I have completed my pre treatment medical history form and have informed my practitioner of any pre existing skin or other medical conditions or treatments or medicines.

Although AMARCO Enterprises Pty Limited, trading as Regul8® Pty Ltd, endeavours to ensure that all clients receive the best possible care and results, at no time does it make any guarantees or undertakings that any Regul8® treatment or product will cure, alleviate, prevent, eliminate, or retard any injury, illness or condition.

PRIVACY POLICY

My personal information is used for the purpose of preparing information and advice about Regul8®.

I understand that I have the right to request a copy of a Privacy Policy from the practitioner/clinic.