Fundamentals Challenge Intake Form - Sari's Natural Medicine

Please complete the following form. Your answers are important for us to make sure you are safe during your Fundamentals Challenge
Your Name(required)
Date of birth/ age(required)
Email address(valid email required)
Phone number(required)
Postal address(required)
Post code(required)
List your past medical history(required)
List your current medical history(required)
List any medications you are taking, prescribed or over the counter(required)
List any supplements or herbal medicines you are taking(required)
Have you done Nutritional Balancing before?
YesNo
List any detoxification procedures you have done before.
List any heavy metals/ heavy toxin exposure you have had if any.
Briefly list your top three health concerns
Briefly list your top three health goals
Thank you for your time. We look forward to working with you during your Fundamentals Challenge and in the future.