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With Dr. Gabriel Nicolaev – Nicolaev Medicine

Thank you for scheduling a consultation with Dr. Gabriel Nicolaev. To provide you with the best possible guidance, please complete this form before your session. Your responses will remain confidential and will help tailor recommendations to your specific health concerns.

Personal Information:

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Please describe your main health concerns or symptoms: *

Have you been diagnosed with any medical conditions? *

Are you currently under medical treatment? *

Lifestyle & Nutrition

How would you rate your overall energy levels? *

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Digestive & Gut Health

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Have you taken antibiotics in the past year? *

Do you take probiotics or digestive enzymes? *

Hormonal & Energy Balance

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Do you take any hormonal or energy-boosting supplements? *

Detox & Environmental Exposure

Have you ever done a detox or cleanse?

Are you frequently exposed to toxins such as: *

Additional Information

Do you have any allergies or food intolerances? *

Anything else he should know before your consultation? *

By submitting this form, I confirm that:
✅ I understand that this consultation is for educational and informational purposes only.
✅ I acknowledge that Dr. Gabriel Nicolaev does not provide medical diagnoses or treatments.
✅ I am responsible for any decisions I make based on this consultation.

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