Evexia Active - BioCeuticals Consultation Questionnaire

EVEXIA ACTIVE - BIOCEUTICALS CONSULTATION QUESTIONNAIRE

Please take your time to complete the following questionnaire.

All questions require a response in order to proceed.

Once you are eligible, you will be given exclusive access to your own BioCeuticals online account. You will also automatically qualify for a VIP Discount on all BioCeuticals products.

If you have any further questions, please email us: hello@evexiaactive.com.au

We look forward to helping you live your best life with health & happiness!
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Age*
years
Height*
cm
Weight*
kg
How did you hear about Evexia Active?*
What do you do for work?*
How would you describe your activity level in your work role?*

Sedentary (mostly seated)Moderate (light activity such as walking)High (heavy labour, very active)
How many hours per day/week do you usually work? Do you work days, afternoons or nights?*
What are your primary health concerns? Please list.*
Describe your symptoms, including frequency & duration.*
When did these symptoms start?*
What makes these symptoms better or worse?*
Is there a family history of this condition(s) or symptoms?*
Do you have any of the following medical conditions? (Please tick all that are applicable).*

ArthritisAsthmaChemical SensitivitiesCoeliac DiseaseDiabetesEpilepsyGlaucomaHeart ConditionHigh Blood PressureInflammatory Bowel DiseaseLactose IntoleranceStomach UlcersThyroid ConditionNone of the aboveOther
Please list any prescription medications or vitamins/supplements that you are currently taking.*
What additional therapies are being undertaken for the given health concern(s)?*
On average, how many hours do you sleep each night?*

Sleep Quality (out of 10). 1 = lowest (minimum) 10 = highest (maximum)*

	1	2	3	4	5	6	7	8	9	10
Sleep Quality

Stress Levels (out of 10). 1 = lowest (minimum) 10 = highest (maximum)*

	1	2	3	4	5	6	7	8	9	10
Stress Levels

How many days per week do you exercise?*

	0	1	2	3	4	5	6	7
Exercise Days

Please list the physical activities/exercise that you participate in outside of work.*
Please list any injuries or surgeries you have had.*
Are you a current smoker?*

YesNo
If yes, how many cigarettes per day? If no, enter 0:*
How many standard alcoholic drinks do you consume per week?*
Do you have any allergies?*

YesNo
If yes, please list. If no, enter 0:*
Are you pregnant?*

YesNo
If yes, how many weeks pregnant. If no, enter 0:*
Are you breastfeeding?*

YesNo
Your current diet could be best characterised as:*

Low FatLow CarbHigh ProteinVegetarian/VeganNo Specific DietOther
What following goals best align with your health & fitness goals?*

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat lossOther
Please list the details of any other practitioners, including your GP, that you are currently seeing. *
Please include Pactitioner's Full Name, Phone Number, Email, and Practice Address.
Please list the BioCeuticals products you are interested in purchasing?*
Your health profile will be assessed to recommend the products that are most suitable for you.
Have you previously used any of the BioCeuticals products listed above?*

YesNo
If yes, please list the BioCeuticals products you have used.*
TERMS & CONDITIONS

1) UPDATING DETAILS

Should any of your details or information provided on this form require changing/updating, it is your responsibility to inform your Practitoner, in writing, of those changes as soon as possible. Evexia Active takes no responsibility for any old, incorrect or false information provided by you, the client, or the consequences of having been provided such information.

2) PRESCRIPTION AND RECOMMEDATION OF BIOCEUTICALS

Any prescription or recommedation of BioCeuticals products will be done so with careful consideration of the information provided by you, the client, on this form. Always consult with your Medical Practitioner or GP first before taking any other medication or supplements.

3) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I agree to consult with my Medical Practitioner or GP before taking any other medication or supplements, including BioCeuticals products. I understand that all the information I have provided will be kept confidential.

4) PHONE CALL AND/OR EMAIL FOLLOW-UPS

I agree to participate in follow-up phone calls and/or emails from Evexia Active, when necessary, for clarification of any information I have provided on this form. NOTE: Any follow-up sessions are for the purpose of confirming eligibility for an Evexia Active x BioCeuticals secure online account and for issuing an accurate prescription/recommendation of BioCeuticals products to you, the client.

5) PERSONAL DETAILS

I agree to provide my Full Name, Email, Phone Number, and Address for the purpose of creating a BioCeuticals account with Evexia Active which will enable me to purchase BioCeuticals products online. I understand that all the information I have provided will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS.*

YesNo
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please verify*
After submitting your form, Maria from Evexia Active will assess and verify the information you have provided and will be in touch to advise your eligibility for an Evexia Active - BioCeuticals online account.

Thank you!
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