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First Name

Surname

Email Address

Address

Blood Group

What are your current Health Issues?

(Digestion)Please tick the appropriate column

	Never	In the past	Recently	Frequently
Heartburn or Reflux

Bloating after Meals

Constipation

Burping, Gas or Wind

Diarrhoea or loose stools

Nausea (feeling like vomiting

Stomach Ulcers or Stomach pain

Gallbladder problems