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Vitamin B12 Consultation
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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
Have you suffered from or had any of the following conditions:
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
Self Injection Guide.pdf
I agree to the Terms and Conditions of sale, specifically those relating to Vitamin B12 self injection home kits.
*
Confirm
Terms & Conditions - Charlotte Emma
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