+44 (0)118 972 1236
INSTITUTE of OLIGOTHERAPY
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

Personal History

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


Memory and Concentration

Nature


Character


Sleep


Infections


Head

Respiratory System


Urinary Tract


Digestive System


Stools
- Frequency
- Consistency
- Colour
- Odour

Cardiovascular System


Osteoarticular System


Skin, Hair and Nails


Endocrine System - Pancreas


Adrenal Glands


Hyperthyroidism


Hypothyroidism


Parathyroid Disturbances


Genitals


Pregnancies
Miscarriages