Consultation Form

Are you attending or receiving treatment from a doctor or specialist?

Yes

No

Are you taking any medication, or herbal remedies (including antibiotics, anticoagulants, Muscle Relaxants, St Johns Wart, Roaccutane)?

Yes

No

Have you been diagnosed with any medical conditions?

Yes

No

Do you regularly drink alcohol?

Yes

No

Are you a strict vegetarian or vegan?

Yes

No

Do you suffer from fatigue or weakness?

Yes

No

Do you have a swollen or sore tongue?

Yes

No

Do you experience tingling or numbness (similar to pins and needles) sensation in your hands and feet?

Yes

No

Do you suffer from low mood or depression?

Yes

No

Is your skin usually pale?

Yes

No

Do you experience dizziness or light-headedness?

Yes

No

Do you have brittle nails?

Yes

No

Do you have indigestion, gas bloating, diarrhoea or constipation

Yes

No

Have you experience unexplained weight loss?

Yes

No

Do you have cold hands and/or feet?

Yes

No

Do you experience difficulty sleeping or have unrestorative sleep (wake from sleep feeling unrested)?

Yes

No

Do you suffer from shortness of breath with minimal exertion?

Yes

No

I confirm that I have read and understood the Self Injection Guide and I agree to carry out the procedure explicitly following the Self Injection Guide.

Confirm

I agree to the Terms and Conditions of sale, specifically those relating to Vitamin B12 self injection home kits.

Confirm

Have you suffered from or had any of the following conditions: