Source Medicine TIPPs Questionnaire
This in-depth questionnaire focuses on general health, plus personal and family history of events that can affect our wellbeing: Toxins, Infections, Physical and Psychological traumas (TIPPs).

The information will be used by your practitioner to decide how best to help you, and is also used (with no personal details) for Source Medicine research. At the end of the form you can request a copy for your own reference.

You can skip complex questions if you do not wish to answer, and address these directly with your practitioner if you want to.

Email address *
Personal Details
Some of this information is used for arranging appointments or for the personalisation of the audio Source Resonances.
Full name *
Your answer
Skype name *
Your answer
Telephone number *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Gender
Ethnic origin
Your answer
Mother tongue (the language/s spoken by your birth mother)
Your answer
Country of residence and local time zone
Your answer
Please confirm that you (and where relevant, your study partner) have read and understood the Client Information Sheet (www.sourcemedicine.zone/client-info)
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