Questionnaire – Human – Allium Healing

This is the Human Questionnaire – here is the link to the Animal Questionnaire

By submitting this questionnaire you are giving Allium Healing permission to store the data provided. Allium Healing will only use your data for the purposes of testing you and providing remedies, it will not be shared in any way with any other party either by electronic or spoken means. We comply fully with Article 5 of the GDPR, which states that data must be ‘collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes’; ‘adequate, relevant and limited to what is necessary’ and ‘kept… for no longer than is necessary for the purposes’.

If you would prefer to send your information by post rather than electronically, here is a pdf version of the questionnaire which you can download, print, complete manually and post to us. Human Questionnaire pdf

NB: When you submit the questionnaire electronically, you will be re-directed to the shop to pay the initial test fee, payment confirms your booking for testing.

Questionnaire - Human

Your full name *

Email *

Phone number *

Date of Birth *

If female, are you pregnant?

Yes

Please list all current physical health problems *

Please list any current mental or emotional issues *

Do you have any emotional ties to animals or people that you struggle with? Or are very strong? Please explain *

Please give brief history of health issues during your life *

Any recurring health problems? *

Is there a family history of certain illnesses? If so please give details *

Have you suffered any bereavements recently?

Are you currently on any medication? *

If yes, what time(s) of day do you take medication?

Have you recently (last 12 months) had any vaccinations or change in medication? *

Please list medications / vaccinations here

How many cups of tea / coffee do you drink each day? *

Are you aware that you could go back through old symptoms during the treatment? *

Are you willing to go through this in order to bring about healing?

NB: Although we test as thoroughly as possible initially, things may change as treatment progresses and you may need a retest to provide different remedies to support you. Do you agree? *

Are you aware that you should NOT take any other homeopathy during treatment? except that which has been supplied by Allium Healing via muscle-testing? However we can suggest and/or supply other remedies providing you are tested first.. *

I confirm that I understand the principles of homeopathy being an energy medicine and that, should any bottle of remedy purchased from Allium Healing be tested, nothing except alcohol or sugar syrup would be found. I confirm that I have sole responsibility for deciding if treatment is correct for me after consultation and I take full responsibility for my treatment once it has been sent to me. I confirm that Allium Healing is not liable in any way for misuse of products sent nor for lack of results from such products since once the items reach me they are under my control and are my responsibility to administer as per the consultation guidelines. *

Your full name *

By entering your full name below you declare all the information you have provided above to be correct to the best of your knowledge and you give consent to Allium Healing to test you – which we will do to the best of our ability. *

I confirm that I request Allium Healing to test me via hair sample provided and understand that no promises of cure have been made. It does not replace medical advice. I am responsible for any withdrawal of medication prescribed by my doctor. I confirm I have read the privacy statement and agree to my details being kept. *

Please give your full address & postcode for us to send remedies to you.

Where did you hear about Allium Healing? *

If 'recommendation' or 'elsewhere' please give details

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If you are human, leave this field blank.

Allium Healing

This is the Human Questionnaire – here is the link to the Animal Questionnaire

Questionnaire - Human

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