What gender do you identify as?

    Are you a smoker?

    How would you rate your stress levels out of 10? (1 = minimal stress and 10 = extremely high stress)

    By submitting this form I agree to the following:
    * I am over 18 years and have the ability to make my own decisions. If not, I have my guardian's/carer's consent
    * I have and will to the best of my knowledge supply correct and relevant information to this particular consultation
    * It is solely my decision to participate in any suggested treatment strategies and I will do so under the guidance of Mel Trebilcock of Melt Nutrition
    I accept all of the above terms: