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Questionnaire (A)
Date:
Name:
Sex (F/M/Other):
Date of Birth:
Primary Symptoms (Non-communicable):
Diabetes Hypertension Arthritis Gout Osteoporosis Vertigo/Dizziness Enlarged Prostate Anxiety Palpitation
Digestive Problems
Irritable Bowel Syndrome Reflux Colitis Constipation Loose-Motion Flatulence Piles
Sleep Hygiene
Insomnia Apnea Sleep-Talking Sleep-Walking Migraine Nerve-Pain Waking-Up-Tired
Skin Disorder
Eczema Asthma Psoriasis Urticaria Eruptions
Menstruation/Menopausal Symptoms
Period Pain/Peri-Menopause/Menopause/Post-Menopause/Hot Flushes/Palpitation
Any Other Symptoms
Brief Medical History
Present Medication
Allopathy:
Alternate:
Your Body is the Best Doctor:
While working towards achieving well-being it is important to keep in mind that one’s body is designed and best equipped to heal itself. We just need to consciously support the body by providing it with the necessary ingredients, micro-nutrients and lifestyle changes that it requires to maintain wellness.
Note:
At Pill Box Project, we are not trying to treat you or medicate you for any specific illness or symptoms. This is not a substitute to prescription medication. We’re only supporting you with the necessary nutrients and micro-nutrients in the form of phyto/food supplements to aid your body. We’re hoping the body will heal itself and achieve a state of well-being with the help of these over-the-counter (OTC) phyto/food supplements.
Please do not discontinue your regular prescription drugs prescribed by your Doctor or for that matter by any other medical professional.