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Enquiry Form >> Health Consultation

Note: Fields marked with * are compulsory.
*Name :
*Surname :
*IC No. :
*Sex :
*Age :
*IBE code :
*Sponsor :
Address 1 :
Address 2 :
Postcode :
Town/City :
State :
*Email Address :
*Tel. No. : -
Office No. : -
*Mobile Phone No. : -
Fax : -
If you have been attended by one of our nutritionist, please select the nutritionist name.
  Nutritionist:


Suffered Diseases: (Please check, you may select more than one disease)

Acne Gout (High Uric Acid) Multiple Sclerosis
Allergy(Skin) Gallbladder disease Myoma Uteri
Amyloidosis Gastritis Menstrual Cramps
Anemia Hepatitis B / Carrier Menopause Discomfort
Asthma H. pylori Infection Osteoarthritis
Bad breath Heart Disease Overweight
Bloating Hand dermatitis Osteoporosis
Bone spur High TG Peptic Ulcer
Constipation Hepatitis C / Carrier Pancreastitis
Colon Polyps High Cholesterol Periodontal disease
Colitis Hemorrhoids Psoriasis
Cystitis Hypertension Pigmentation
Cataracts Hair loss Pneumonia
Chronic fatigue syndrome Impotence Prostate disorders
Cirrhosis of the liver Infertility (Female) Rheumatoid
Diabetes Insomnia Rhinitis/Sinusitis
Diarrhea Infertility (Male) Sciatica
Depression Irregular Menstuation Stroke
Endometriosis Kidney stone Thyroid disorders
Eczema Kidney Disease Tinnitus
Exercise Injury Lupus Ulcer (Mouth)
Fatty Liver Muscle cramps Urinary infection
  Migraine Vaginitis

Tumor:
  (area or organs affected)

Cancer:
  (area or organs affected)
  (Stage)
  (Metastases to)

Please select the most serious diseases that you wish our nutritionist to attend to. ie: Start from disease most severe to disease less severe.
1st  
2nd  
3rd  
4th  
5th  

Other Diseases:

*Present Condition :
*Enquiry Detail :

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