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Wellbeing Form

Please only complete this form if you have been instructed to by one of our Health Coaches, Stephanie Ng or Sirinie Wanigaratne.

Please use format day/month/year e.g. 12/05/1979
Are you currently taking any supplements?
Do you suffer any of the following?
Do you experience any of the following digestive difficulties?
Rate the health of your digestion overall
How often do you have a bowel movement?
Do you experience any food allergies or intolerance?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.