Complete and submit our online form to assess how your trace element status could be affecting your health. Please note that this cannot be regarded as an individual diagnosis of your health; it is only an initial assessment based on the facts submitted. For a more thorough evaluation it would be necessary to have a full consultation with an Oligotherapy practitioner. Personal Details First Name* Last Name Address Landline* Work Phone Mobile Email* Weight Height Date of Birth Reason for Consultation Expectation Alcohol (units per week) Tobacco (per day) Caffeine (per day) Family History Stroke Cancer Heart Disease Neuropsychiatric Disease Obesity Gout Allergies Blood Disease Joint Disease BP Problems Arthritis TB Personal History Measles Vaccinations Bronchitis Scarlet Fever Tonsilitis Asthma Chicken Pox Glandular Fever Allergies German Measles Colds Eczema Flu Whooping Cough Operations Accidents In the last two years have you received treatment from a medical or alternative practitioner. If yes please give details: If you are taking any medication/natural remedies please give details: General Health Chronic tiredness, general lassitude Tiredness in the morning Progressive tiredness owing to lack of resistance Tiredness in the morning, reappearing in the afternoon Irregular tiredness, exhaustion Tires after effort Refreshed by effort, tireless in the evening Has always been like this Memory and Concentration Selective, recent memory disturbances Reduced in relation to tiredness Reduced with age Very poor Nature Very energetic Moderately energetic Less energy than before Lacking in energy Slight pessimism, anxiety, emotional liability Pessimism with depresssion Mental state neither good nor bad Mental state fluctuating Optimism Character Calm, thoughtful, self-controlled Nervous, choleric, easily 'carried away', impatient Nervous, anxious, emotional Apathetic, listless, general lack of interest Alternating moods Sleep Need for lot of sleep Duration of sleep reduced because of intense life Poor sleep with anxiety, waking during the night Difficulty getting to sleep Poor sleep with nightmares Drowsiness Infections Susceptible to infections Very susceptible to infections Adenitis Staphyloccal infection TB Others Head Headaches, migraines Auditory disturbances Dizziness, drop in BP, feel faint Dizziness, low BP, feeling faint Respiratory System ENT infections Hayfever Hayfever with infections complications Asthma Bronchitic Asthma Bronchitis Sinusitis Pleurisy Breathlessness Urinary Tract Frequent or infrequent urination Cystitis Bed-wetting Incontinence Digestive System Irregular appetite Lack of appetite Food intolerance Nausea Constipation Diarrhoea Alternating Constipation/Diarrhoea Slow Digestion Colic Wind/Bloating/Flatulence/Burping Peritonitis Gastritis Duodenitis Ulcer Chronic Enterocolitis Colitis/Rectocolitis/Sigmoiditis Stools - Frequency - Consistency - Colour - Odour Cardiovascular System Hypertension Hypotension Palpitations Tachycardia Pericarditis Angina pectoris oppression, radiation, anguish Varicose veins Haemorrhoids Oedema of the legs and/or ankles Nocturnal cramps Tingling Cold or numb extremities Blue/purple fingers or extremities (Acrocyanosis) Excessive urination at night Osteoarticular System Fleeting pains Chronic, progressive pain, deformities Joint disease; pain at start of day, every day Arthritis; pain all day during 'flare up' Gout Osteomyelitis Skin, Hair and Nails Non-infected eczema Infected eczema Pruritis (itching), Urticaria (hives) Quincke's Oedema Brittle hair and nails Hair loss Endocrine System - Pancreas Undigested stools Putrid diarrhoea Weight loss Weakness Exhaustion Ravenous Appetite Adrenal Glands Loss of strength and physical weakness Hypotension Depression Vomiting Diarrhoea Drowsiness Hyperthyroidism Hypertension Variation in weight Hot flushes Nervousness Palpitations Diarrhoea Hypothyroidism Hypotension Slow-wittedness Apathy 'Chilly' feeling Constipation Parathyroid Disturbances Hyperreflexia (muscle twitching) Hyperexcitability (excessive mental and physical activity) Cardia Arrhythmias, Tachycardia Muscular contractures Spasms Genitals Frigidity, Impotence Frequent, heavy, painful menstruation Infrequent, light menstruation Irregular menstruation Menstruation absent Menopausal disturbances Sterility Pregnancies Miscarriages