How Can We Help? • Mr Bee's Herbs

Medical Questionnaire

This questionnaire can help us recommend the best products for you and ensure you get the best use out of the ones best suited for you.
Please answer each question below to the best of your ability and we would follow up with you within 12 – 24 hours post submission.

Do you have a primary care physician?

Yes No

List all medications and supplements you are currently taking:

Are you allergic to any drugs? If yes, please, provide details

Last Doctor visit:

Reason for your last Doctor visit:

Are you currently pregnant or breastfeeding?

Yes No

Do you smoke Tobacco?

Yes No

Past or present medical history: (Check all that apply)

Surgeries (Include Year or Age at time of surgery)

How would you describe your daily activity level?

Sedentary (little to no exercise) Lightly active (light exercise or daily activities) Moderately active (exercise 3-4 times a week) Very active (exercise 5-7 times a week)

Do you have any specific health goals? (Check all that apply)

What products are you most interested in?

Have you experienced any adverse reactions to natural herbs or supplements?

Yes No

If yes, please specify:

Do you have any additional comments, concerns, or health conditions we should know?

Anxiety/Depression

Me Family Member

Anemia

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Asthma

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Bladder/Urinary Tract Infection

Me Family Member

Blood Clots

Me Family Member

Bone or Joint Infection

Me Family Member

Cancer

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Chest Pain/Angina

Me Family Member

Circulation Problems

Me Family Member

Diabetes

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Epilepsy

Me Family Member

Eye Problem/Infection

Me Family Member

Fibromyalgia

Me Family Member

Headaches

Me Family Member

High Blood Pressure

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Heart Problems

Me Family Member

Hepatitis/Liver Problems

Me Family Member

Kidney Problem/Infection

Me Family Member

Lung Problems

Me Family Member

Multiple Sclerosis

Me Family Member

Osteoarthritis

Me Family Member

Osteoporosis

Me Family Member

Other Arthritic Condition

Me Family Member

Pelvic Inflammatory Disease

Me Family Member

Rheumatoid Arthritis

Me Family Member

Seizures

Me Family Member

Sexually Transmitted Disease/HIV

Me Family Member

Stroke

Me Family Member

Substance Abuse

Me Family Member

Thyroid Problems

Me Family Member

Ulcers

Me Family Member

Other

Me Family Member

*Disclaimer: The information and recommendations provided through this questionnaire are for informational purposes only and are not intended to replace professional medical advice, diagnosis, or treatment. We are not licensed medical professionals. Always consult your physician or healthcare provider before starting any new supplement or changing your health regimen. If you have any concerns about your health, please seek advice from a qualified medical professional.