Health Questionnaire

Let's understand
your health picture.

This questionnaire helps Kathleen understand your health history before your consultation. It takes around 5–8 minutes. Your answers are completely confidential.

Don't fill:

Step 1 of 6

About you

1 / 6

What is your gender?

Male Female Prefer not to say

Please select an option to continue.

What is your age?

Under 18 18–24 25–34 35–44 45–54 55–64 65+

Please select an option to continue.

What is your email address? — so Kathleen can follow up with your results

Please enter a valid email address.

Before you begin, could you briefly share what led you to explore natural remedies? — e.g. struggling with sleep, digestive issues, or something else

Step 2 of 6

Energy, mood & mind

2 / 6

How often do you experience the following?

Do you experience low or negative moods?

Never Sometimes Often Always

Please select an option to continue.

Do you struggle with problem-solving or critical thinking tasks?

Never Sometimes Often Always

Please select an option to continue.

Do you experience anxiety, nervousness, or restlessness?

Never Sometimes Often Always

Please select an option to continue.

Do you find it difficult getting to sleep and/or staying asleep?

Never Sometimes Often Always

Please select an option to continue.

Do you feel tired and fatigued?

Never Sometimes Often Always

Please select an option to continue.

Do you experience stress or tension?

Never Sometimes Often Always

Please select an option to continue.

Do you experience difficulty remembering things or concentrating?

Never Sometimes Often Always

Please select an option to continue.

Are you currently taking antidepressants?

Yes No

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Step 3 of 6

Hormonal & physical

3 / 6

Do you experience low sexual drive or loss of libido?

Never Sometimes Often Always

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Have you noticed a decrease in muscle mass or strength?

Yes No

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Have you noticed an increase in body fat, especially around the waist?

Yes No

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Do you experience muscular pain?

Never Sometimes Often Always

Please select an option to continue.

How often do you suffer from muscle cramps?

Never Sometimes Often Always

Please select an option to continue.

Are you anaemic?

Yes No

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Step 4 of 6

Digestive health

4 / 6

Do you experience difficulty digesting food?

Never Sometimes Often Always

Please select an option to continue.

Do you suffer stomach cramps?

Never Sometimes Often Always

Please select an option to continue.

Is your stool very soft or loose (diarrhoea)?

Never Sometimes Often Always

Please select an option to continue.

Do you regularly experience bloating?

Never Sometimes Often Always

Please select an option to continue.

How often do you experience constipation?

Never Sometimes Often Always

Please select an option to continue.

Do you suffer from acid reflux?

Never Sometimes Often Always

Please select an option to continue.

Do you find it difficult to digest a fatty meal?

Never Sometimes Often Always

Please select an option to continue.

How regular are your bowel movements?

Less than once a day Once a day Multiple times a day

Please select an option to continue.

When waking, do you have a bowel movement?

Yes — without stimulants Yes — with stimulants (caffeine/coffee) No — later in the day

Please select an option to continue.

Step 5 of 6

Body, skin & immune

5 / 6

Do you have a skin condition? (e.g. eczema, acne, psoriasis)

No Yes

Please select an option to continue.

How often do you experience joint pain?

Never Sometimes Often Always

Please select an option to continue.

Do you suffer from headaches or migraines?

No Yes

Please select an option to continue.

Usually, are you slow to recover from colds? (Normal is 7–10 days)

Yes No

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Do you suffer from nasal congestion?

Never Sometimes Often Always

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Do you suffer from a sore or irritated throat?

Never Sometimes Often Always

Please select an option to continue.

Do you suffer from hayfever?

Never Sometimes Often Always

Please select an option to continue.

Do you suffer frequent bouts of coughing?

Never Sometimes Often Always

Please select an option to continue.

Step 6 of 6

Medical history & lifestyle

6 / 6

This information helps Kathleen understand any contraindications and ensure your herbal formula is safe for you.

How many coffees or caffeinated drinks do you consume each day?

0 1 2 3+

Please select an option to continue.

How many standard alcoholic drinks do you consume in a week?

0 1–2 2–4 6+

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Do you have a liver condition or a history of liver disease?

YesNo

Please select an option to continue.

Have you been diagnosed with any heart disease?

YesNo

Please select an option to continue.

Do you have high blood pressure and/or a potassium deficiency?

YesNo

Please select an option to continue.

Are you being treated for cancer or have had cancer in the last 5 years?

YesNo

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Do you take regular aspirin or blood thinners?

YesNo

Please select an option to continue.

Do you have any kidney disease?

YesNo

Please select an option to continue.

Are you being treated for any autoimmune or chronic inflammatory disorders?

YesNo

Please select an option to continue.

Have you been diagnosed with diabetes?

YesNo

Please select an option to continue.

Are you undertaking hormone replacement therapy?

YesNo

Please select an option to continue.

Are you currently taking any prescription medications?

No Yes

Please select an option to continue.

Do you suffer from period pain?

YesNoN/A

Please select an option to continue.

Are you currently taking the contraceptive pill?

YesNoN/A

Please select an option to continue.

Do you have any known allergies to herbal extracts?

No Yes

Please select an option to continue.

Thank you

Your responses have
been received.

Kathleen will review your answers before your consultation. If you haven't booked yet, you can do so below.

Book a consultation

Let's understandyour health picture.

About you

Energy, mood & mind

Hormonal & physical

Digestive health

Body, skin & immune

Medical history & lifestyle