Naturopathic Healing Support | Holistic Nutritional Consultations

To be filled by the client.

Please ensure the computer is set to sleep mode if you step away for an extended period before submitting the form.

Name:

Date of Birth:

Age:

Gender:

Blood type if knpwn:

Address:

Country:

Telephone number:

E-mail address:

Marital status:

Children:

Occupation:

Height in cm:

Weight in Kg:

Waist in cm:

Referred by:

GP Name:

GP Address:

Tel. number:

Permission to contact GP?

Yes No

Please put any extra details about any medication in the big box.

Other notes (including hormonal contraceptive use):

Please include all current supplements, and any herbal or natural remedies (including topical).

Please put any extra details about any supplements and therapies in the big box.

Any other notes, including therapies:

Information on conditions like cancer, diabetes, and autoimmune conditions.

Please put any extra details about any family member in the big box.

Any recent test results (last 6 months) or diagnosed conditions:

Terms and Conditions

Good naturopathic nutrition supports the body’s natural defences and resistance. However, no claim can be made about the efficacy of any naturopathic nutritional advice.
The client is responsible to contact his/her GP or health care about any health concerns s/he has.
The client advised to inform his/her GP about the naturopathic nutrition protocol and any complementary medicines s/he follows.
It is very important and necessary that the client informs the nutritionist/practitioner about any medical diagnosis, prescription medication, herbal medicine or food supplements or over-the-counter medication, as they may affect the naturopathic nutritional programme.
If a client is unclear about any part of the naturopathic nutritional consultation plan, then s/he should contact the nutritionist immediately for clarification.
Naturopathic nutritional programme and supplement plan have a time frame, beyond which the client shouldn't continue with them unless discussed with the nutritionist.
Face-to-face or video consultation may take up to two hours. DIY part 2 form filling may take the same time, but can be done piece by piece whenever convenient.
All provided information is strictly confidential and stored in line with General Data Protection Regulation guidelines.
The clients apply the naturopathic nutritional programme on their own diligence and responsibility.

I have read and agree to the Terms and Conditions

Full Name: