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b12 consultation form
First name
Surname
Date of birth
Email address
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Address Line 1
Address Line 2
Town / City
Do you suffer from fatigue or weakness?
Yes
No
Postcode
Do you have difficulty concentrating or a poor memory?
Yes
no
Do you suffer from numbness or tingling feeling in your hands or feet?
Yes
No
Do you feel restless?
Yes
No
Do you suffer from low mood or depression?
Yes
No
Are u pregnant or breast feeding?
Yes
No
Your label Have you had B12 injection before?
Yes
No
Do you experience light headiness or dizziness?
Yes
No
Do you have low potassium Levels?
Yes
No
Do you suffer from any heart condition? or do you have a irregular or fast heartbeat?
Yes
No
Please consent to understanding the possible side effects
pain, swelling or itchy skin where your injection was given
Feeling or being sick (nausea or vomiting)
diarrhoera
headaches
feeling dizzy
hot flushes
Who is your practitioner?
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