What service are you looking for today?*
Gender assigned at birth*
Height*
Weight*
Do you have a family history of any of the following?*
Do you see a doctor or specialist for any ongoing health conditions? If so, please list the conditions and the type of doctor/specialist.*
Do you have any ongoing health conditions? Autoimmune diseases, thyroid issues, digestive disorders (e.g., IBS, Crohn’s), cardiovascular diseases, mental health conditions, asthma, eczema, menstruation irregularities, other female health issues, etc*
If you currently take any medications or supplements, please list them here, (name, dose, regularity) or say "None" if you don't take any.*
Please list any antibiotics you've taken in the last 6 months and specify why they were prescribed*
Do you experience any of the following?*
Choose your current health/wellness goals – choose up to 3:*
Please list your top 3 health priorities*
Do you follow a specific diet? (Vegan, Keto, Low carb etc)*
How many times do you eat fish per week? Please specify which fish*
How much dairy do you consume per day? Please specify the types of dairy*
How much protein do you eat per day? Please specify the types of protein*
If applicable, please list any allergies or intolerances you have*
On average, how many fruits do you eat per day?*
On average, how many vegetables do you eat per day? *
How much tea and coffee do you drink per day? Please specify*
On average, how many and how much alcohol do you drink per week? *
How often do you exercise per week?*
Do you smoke or vape? If yes, please specify which and how often per day*
How would you describe your activity level? *
Your fitness routine includes (choose all that apply):*
What do you care most about when exercising? (choose as many as you like):*
On average, how many hours of sleep do you get per night?*
How would you rate the quality of your sleep? (Light, Restful or Interrupted)*
On a scale of 1-10, how would you rate your current stress levels? (1 = No stress at all, 10 = Extremely stressed, feeling overwhelmed) Please list the reason/s for stress*
When it comes to living a healthy lifestyle, you are:*
Please confirm that you are happy to receive information about your recommended supplements, tests, or a suggestion for a comprehensive appointment via email*
Please confirm that you are happy for Oranga to contact you with product launches, exciting updates, and company news*
