HAIR TEST QUESTIONNAIRE

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DNA HAIR ANALYSIS – APPLICATION 

 Personal Details (Strictly Confidential) 

Name:                                                    M/F (please circle) Tel:  

Address: 

Postcode:                                                        Mobile:                                         Landline:

Email:                                                         Age:                 Height: 

Occupation: 

First Test             Retest          (please tick) 

 How did you find us? 

 Medication (prescription only) 

Supplements 

Medical Conditions 

                                                                                                                                                Do you smoke? 

 Symptoms 

Please list the top three symptoms which you are currently suffering from, in order of seriousness. You can write a full medical history on the reverse of this form if you wish. 

 1 

 2 

 3  

Hair 

Place a minimum of three hairs - anywhere on the body will do - in the space below making sure that the root of the hair is attached. PLEASE DO NOT TAPE OVER THE ROOT. 

Medical History – please enclose extra pages if this space is not enough 

CREDIT CARD PAYMENT DETAILS

 VISA                                             SWITCH                                      OTHER 

 CARD NO:                         /                   /                     /         

 START DATE:            /           EXPIRY DATE:           /            SECURITY CODE:                

                                                                                              (Last 3 digits on white strip on back of card above signature)

ISSUE NO:  

Integral Health

8 Waterers Rise

Knaphill

GU21 2HU

Please Call Now

01483 522133