Online Health Questionnaire

This health questionnaire from SuperPharmacyPlus helps ensure safe, personalised supply of practitioner-only probiotics. Biome Australia requires verification from a pharmacist before supplying these products, based on the information provided in this form. Please note that this information is confidential and used only for assessing the suitability of purchase.

Age

Gender

List your allergies

List your intolerances

Are you pregnant or breastfeeding

Please list any medication you are taking or have taken in the last 12 months

Please list any supplements you are taking or have taken in the last 12 months

Please list any medical conditions that you currently have

Describe your current symptoms

When did your symptoms begin

Is there anything that makes your symptoms feel better or worse

Do you have a family history of these symptoms

Describe your diet (how many meals do you eat per day and the types of foods and beverages you consume

How many hours do you sleep at night?

Please rate the quality of your sleep out of 5

Please rate your general stress levels out of 10 (where 0 is no stress and 10 is extreme stress

Do you smoke or vape If so how many times per day do you smokevape

Do you drink alcohol If so how many standard drinks do you consume per week

How many hours of exercise do you do per week

What type of exercise do you do

How and when would you like to be contacted by a health practitioner for discussion of your health questionnaire