Personalization Questionnaire

Your personalized herbal formula starts here. This questionnaire is your opportunity to share the details we need to craft a product uniquely tailored to your goals, preferences, and lifestyle. It’s a simple and essential step to ensure your custom formula reflects what matters most to you.

Completing this questionnaire takes about 15–30 minutes, and you’re welcome to skip any questions that don’t apply or feel comfortable for you. Rest assured, your responses are handled with care and used only to create your custom herbal product.

Thank you for taking the time to complete this comprehensive assessment. Your responses will assist us in tailoring our consultations and herbal solutions to meet your unique health needs. Rest assured, your information is handled with the utmost confidentiality, prioritizing your privacy and trust.

Personal Information

First Name *

Last Name *

Email *

Phone *

Age *

Gender *

Location *

Occupation *

HEALTH PROFILE

General Health

1. Existing Health Conditions *

2. Medications & Dosage (List all) *

3. Allergies (Food, Medications, etc) *

4. Past Surgeries or Medical Procedures *

Reproductive Health

5. Severity of Menstrual Pain (Scale of 1-10) *

6. Current Treatments or Remedies Used *

8. Any fertility concerns or treatments undergone? *

Sexual Health

9. Are there any specific concerns or issues regarding your sexual health that you'd like to discuss or disclose? *

10. History of sexually transmitted infections (STIs) or reproductive health challenges? *

11. Current contraceptive methods or family planning considerations? *

12. Any treatments or interventions related to sexual health? *

Cardiovascular Health

13. History of heart disease, high blood pressure, or other cardiovascular issues? *

14. Any family history related to heart conditions? *

Respiratory Health

15. Any history of asthma, chronic bronchitis, or respiratory issues? *

16. Allergies to environmental factors impacting breathing? *

Endocrine Health

17. Family history of diabetes, thyroid issues, or hormonal imbalances? *

18. Any signs or symptoms related to these conditions? *

Musculoskeletal Health

19. Any joint pain, arthritis, or musculoskeletal conditions? *

20. Physical limitations or chronic pain in muscles or joints? *

Neurological Health

21. History of migraines, headaches, or other neurological conditions? *

22. Symptoms like numbness, tingling, or memory-related issues? *

Dermatological Health

23. Skin conditions, allergies, or sensitivities? *

24. Any ongoing dermatological treatments or concerns? *

Dental and Oral Health

25. Dental issues or concerns? *

26. Any oral health conditions impacting overall well-being? *

Vision and Auditory Health

27. Vision or hearing impairments? *

28. Any issues affecting sight or hearing? *

Cognitive Health

29. Any history of memory issues, cognitive decline, or neurological conditions affecting cognitive function? *

30. Any concerns about focus, concentration, or mental clarity? *

31. Are you currently using any supplements or medications to support cognitive health? *

COVID-19 Related Health

32. Vaccination status for COVID-19? *

33. Have you experienced or do you suspect any symptoms of long COVID? *

Environmental Concerns

34. Do you live in proximity to any environmental factors (such as heavy metals, pollutants, toxins, industrial areas) that might impact your health or have you experienced any related health issues? Please describe any concerns you might have about your environmental surroundings and their impact on your well-being. *

Family Health History

35. Any significant medical conditions or hereditary health issues among immediate family members? *

Communication Preferences

Preferred Mode of Communication for Follow-ups: *

Additional Comments or Information

Any other details or concerns you'd like to share? *

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Personalization Questionnaire

Country/region

Country/region

Personalization Questionnaire

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