Initial Consultation Form:

If you’d like an initial consultation, please fill out the form below and click submit. You will be contacting regarding your form as soon as possible. Or if you prefer email contact@syndromesolutions.com and you will be sent a hard copy which you can fill out and email back to us.

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Full Name *

Date of Birth *

Email *

Phone Number *

Address *

Current GP Name and Address *

Diagnoses from GP and other health issues (e.g. intolerances) including date diagnosed *

Height

(optional)

Weight

(optional)

Past prescribed medications (this includes antibiotics, PPIs like omeprazole)

Current prescribed medication

Current Supplements

Your Current Symptoms

Please as much detail as you are able

Previous Treatments for your condition

Please state your treatments and whether they helped or not so we can better focus our efforts

Current Diet Type

e.g. Vegetarian, Vegan

Typical daily meal example

How would you describe your personality? E.g. Outgoing. Tell us a little about yourself as a person?

Where did you hear about syndrome solutions?

What do you know already about your condition?

In your own words describe the onset of your condition. Include any symptoms you experienced before diagnosis. Did your condition begin suddenly or gradually? Did you experience any mental or physical stress before your condition started?

Submit