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1hls quesLlonnalre ls deslgned Lo provlde your nuLrlLlonlsL wlLh all Lhe lnformaLlon necessary Lo bulld you an lndlvldual
program speclflcally Lallored Lo your needs. lease provlde deLalls as fully and accuraLely as posslble. lf aL any Llme you need more
space please conLlnue on a separaLe sheeL.
LkSCNAL DL1AILS
1lLle______ llrsL name____________________ LasL name________________ MarlLal SLaLus ____________
Address __________________________________________________________________________________
______________ osL Code _____________ L-mall _______________________________________________
1el. number (moblle)__________________________ 1el. number (work)_____________________________
uaLe of 8lrLh ____________ Age __________ CccupaLlon _________________________________________
nLAL1n kCIILL
WhaL ls your maln reason for seeklng nuLrlLlonal advlce? __________________________________________
WhaL ouLcome are you hoplng Lo achleve? ______________________________________________________
lease llsL your healLh concerns you would llke Lo focus on, ln order of lmporLance? ConLlnue on a separaLe
sheeL lf you need more space.

PealLh roblem (e.g.
arLhrlLls)
ManagemenL so far (e.g. C,
operaLlon, exerclse,
paraceLamol eLc.)
under whaL
clrcumsLances does
Lhe healLh problem
lmprove/ worsen?
CnseL
(daLe)
uuraLlon
1.





2.





3.





4.





3.





Pave you had any recenL healLh LesLs? lease speclfy or aLLach, lf approprlaLe _________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Pave you had any oLher ma[or surgery, blopsles, dlagnosed medlcal condlLlons, slgnlflcanL perlods of lll
healLh or do you suffer from any chronlc or nlggllng healLh problems? (please glve deLalls e.g. hlgh blood
pressure, frequenL colds, recurrenL urlnary lnfecLlons eLc.) _________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
uo you suspecL your sympLoms relaLe Lo a parLlcular evenL or Llme ln your llfe?_________________________

MLDICA1ICN & kLMLDILS
lease llsL anyLhlng you Lake regularly lncludlng C prescrlbed medlcaLlon, self-prescrlbed medlcaLlon (e.g.
palnklllers) nuLrlLlonal supplemenLs, herbal or homeopaLhlc remedles. ConLlnue on a separaLe sheeL lf necessary.

8emedy









uose CondlLlon belng LreaLed lrequency & uuraLlon






AnLlbloLlc hlsLory: please sLaLe when and why you lasL Look anLlbloLlcs plus any prevlous Llmes you can
remember:






CUk VI1AL S1A1IS1ICS

_____ WhaL ls your normal blood pressure?
_____ your resLlng pulse raLe per mlnuLe? (!"# %&"#'( )*
%+,,+-. ("/-0 1*'23*( 2-( 42'5 /&*- !"# ,26* !"#1
7#'%*8 9"#-, ,&* -#5)*1 ": )*2,% +- ;< %*4"-(%).
________ your currenL welghL? (wlLhouL cloLhes)
________ your helghL? (wlLhouL shoes)
________ your walsL clrcumference? (lf known)
________ your hlp clrcumference? (lf known)
________ your blood Lype? (lf known)
________ ls your welghL sLable, lncreaslng or decreaslng?
______ uld you have Lhe normal lmmunlsaLlons as a chlld?
CUk IAMIL nIS1Ck

uo you have a famlly hlsLory of dlsease or allergles? (e.g.
hearL dlsease, dlabeLes, asLhma, eLc.) SLaLe dlsease, age aL
onseL & gender.

CrandparenLs: ____________________________________
________________________________________________
arenLs: ________________________________________
________________________________________________
Slbllngs: _________________________________________
________________________________________________
Chlldren: ________________________________________
________________________________________________

CUk DAIL LIIL
_____ uo you have any chlldren? lf so, how many? __
_____ uo you en[oy your dally llfe?
_____ Pow many people depend on your supporL?
_____ uo you feel supporLed by people around you?
_____ Are you recenLly separaLed/dlvorced/a new
parenL?
_____ Are you recenLly bereaved?
_____ Pave you moved house or changed [obs
recenLly?
_____ uo you work long or lrregular hours?
_____ ls your workload blgger Lhan you can manage?
_____ Are you under slgnlflcanL sLress ln any oLher
way?
_____uo you feel gullLy when you are relaxlng?
_____ uo you have a perslsLenL drlve for achlevemenL
_____ Are you especlally compeLlLlve?
_____ uo you ofLen do 2 or 3 Lasks slmulLaneously?
_____ uo you Lake regular exerclse?
_____ ls your [ob acLlve?
_____ uo you have any acLlve hobbles?
_____ uo you have dlfflculLy geLLlng Lo sleep?
_____ uo you experlence unlnLerrupLed sleep?
WhaL do you do for relaxaLlon? ________________-
________________________________________
8CD SCAN
lease unuL8LlnL or PlCPLlCP1 any condlLlons LhaL you
regularly experlence
na|r
olly, dry, poor condlLlon, brlLLle, Lhlnnlng, premaLurely
grey, dandruff, lncreased faclal halr, lncreased body halr,
decreased body halr
Mouth
sore Longue, LooLh decay, mouLh ulcers, bad breaLh, sore
LhroaLs, poor sense of LasLe, excess sallva, dry mouLh,
dlfflculL swallowlng, hoarse volce, glnglvlLls, bleedlng gums,
cold sores, chronlc coughlng, frequenL need Lo clear LhroaL,
swollen or dlscolored Longue/gums/llps, canker sores
Lyes
burnlng, grlLLy, proLrudlng, prone Lo lnfecLlon, sLlcky,
waLery, lLchy, palnful, poor nlghL vlslon, dry, caLaracLs,
senslLlve Lo llghL, bags or dark clrcle, swollen eyellds,
blurred vlslon, double vlslon, falllng eyeslghL, yellowlsh
Nose
sLuffy, congesLed, runny, frequenL nose bleeds, prone Lo
snorlng, slnuslLls, hay fever, posL-nasal drlp, rhlnlLls,
sneezlng, poor sense of smell
Musc|es
Lender, sore, cramps, spasms, LwlLches, loss of Lone,
wasLlng, weak, sLlff, frozen, 'resLless legs', numbness
Sk|n
dry, rough, flaky, scaly, puffy, pale, brown paLches, change
ln moles or leslons, premaLurely llned, congesLed, olly,
clammy, yellow, flushlng/hoL flushes, halr loss, acne,
plmples, rosacea, eczema, dermaLlLls, psorlasls, rashes,
bolls, hlves, lLchlng, sLreLch marks, cellullLe, easy brulslng,
Lhread velns, varlcose velns, rlngworm, allerglc reacLlons,
excesslve sweaLlng
Gut
bloaLed, Lender, cramplng, dlsLended, nausea, sensaLlon of
fullness, acld reflux, hearLburn, flaLulence, belchlng,
passlng gas, churnlng, palnful, lrrlLable bowel syndrome,
coellac, hlaLus hernla, dlverLlcula, polyps, hemorrholds,
ulcers, slugglsh, senslLlve, consLlpaLlon, dlarrhoea
nands
dry, cracked, eczema, sore [olnLs, puffy, cold, chllblalns,
numbness, Llngllng, feel clumsy & uncoordlnaLed, poor
clrculaLlon
We|ght
underwelghL, excesslve welghL, waLer reLenLlon,
compulslve eaLlng, blnge eaLlng/drlnklng, cravlng cerLaln
foods,
Lnergy
laLlgue, slugglsh, leLhargy, hyperacLlve, resLless, dralned,
Llred
Mood
(please underllne your predomlnanL sLaLes - even lf
Lhey confllcL) depressed, anxlous, fearful, nervous,
Lense, angry, lrrlLable, aggresslve, happy, balanced,
opLlmlsLlc, sad, pesslmlsLlc, Llred, can'L be boLhered,
hyperacLlve, cheerful, aglLaLed, easlly upseL, Learful,
[lLLery, frlghLened, exploslve, penL up, worrled,
annoyed, overwhelmed, sulcldal, flucLuaLlng, mood
swlngs
nead
headaches, mlgralne, sLlff neck, fuzzy headed,
dlzzlness, poor balance, poundlng head, feellng of
hangover, unexplalned paln, lnsomnla
M|nd
forgeLful, dlfflculLy learnlng new Lhlngs, easlly
confused, dlfflculL concenLraLlng, poor memory,
confuslon, poor comprehenslon, easlly frusLraLed,
easlly dlsLracLed, dlfflculLy maklng declslons, poor
comprehenslon, poor physlcal coordlnaLlon, sLuLLerlng
or sLammerlng, slurred speech, can'L swlLch off, loss of
lnLeresL ln dally llfe, fogglness, dyslexla, dyspraxla,
hyperacLlve, panlc aLLacks, no moLlvaLlon
neart
lrregular or sklpped hearLbeaL. 8apld or poundlng
hearLbeaL, chesL paln
Chest
frequenL colds and chesL lnfecLlons, asLhma,
bronchlLls, dlagnosed hearL condlLlon, palplLaLlons,
chesL dlscomforL/paln, shorL of breaLh, dlfflculLy
breaLhlng, wheezlng, perslsLenL cough, nolsy
breaLhlng, shorLness of breaLh,
Io|nts (flngers, knees, back, shoulders eLc.)
palnful, achy, lnflamed, swollen, sLlff, rheumaLlc,
arLhrlLlc, achlng, sore, dlfflculLy bendlng, reduced
moblllLy, unsLeadlness, slow movemenL, sLlff or
llmlLed movemenL
Gen|ta|s
lLchy, cysLlLls, Lhrush, ulcers, warLs, herpes, groln paln,
prosLaLlLls, pelvlc lnflammaLory dlsease, lmpoLence,
palnful lnLercourse, vaglnal dryness, palnful or
frequenL urlnaLlon, unexplalned dlscharge
Na||s
fraglle, dry, brlLLle, flaky, peellng, spllLLlng, hangnalls
(spllL cuLlcles), rldged, spoon shaped, whlLe spoLs on
more Lhan 2 nalls, horlzonLal whlLe llnes, Lhlckened or
'horny, dark nalls, pale nall bed, lnfecLed
Legs & Ieet
resLless legs, swollen, achlng, aLhleLe's fooL, fungal
nalls, burnlng feeL, Lender heels, gouL, sclaLlca, cold
feeL, Llngllng, numb, prlckllng.

Important Symptoms:
lease lndlcaLe by under||n|ng lf you suffer from any of Lhe
followlng sympLoms whlch may requlre addlLlonal medlcal
care:
perslsLenL or unexplalned paln, unexplalned bleedlng or
dlscharge from nlpple, vaglna or recLum, blood ln spuLum,
vomlL, urlne, sLools, breasL lumps, calf swelllng, dlfflculLy
swallowlng, excesslve LhlrsL, lncreased urlnaLlon, lnablllLy Lo
galn or lose welghL, loss of appeLlLe, paralysls, slurred
speech, unexplalned brulslng, rash or welghL loss, black
Larry sLools, palnless ulcers or flssures, bleedlng ln
pregnancy
CUk 1CkIC LkCSUkL
_____ uo you llve, exerclse or work ln a clLy or by a busy
road?
_____ uo you spend a loL of Llme on busy roads?
_____ uo you llve close Lo an agrlculLural area?
_____ uo you smoke? lf so, how many a day? _________
_____ uo you llve or work ln a smoky aLmosphere?
_____ uo you spend a loL of Llme ln fronL of a 1v or vuu?
_____ uo you spend a loL of Llme on a moblle phone?
_____ uo you sunbaLhe a loL?
_____ Are you a frequenL flyer?
_____ Are you exposed Lo chemlcals Lhrough work or hobby?
_____ uo you heaL, freeze or wrap food ln plasLlcs?
_____ uo you floss your LeeLh regularly?
_____ Are your LeeLh fllled wlLh mercury amalgams?
LA1ING nA8I1S
Whlch are your favourlLe foods? _______________________
Whlch foods do you dlsllke? ___________________________
Whlch foods do you crave? ____________________________
Whlch foods would you flnd hard Lo glve up? _____________
_____ uo you caLer for a speclal dleL ln Lhe household?
_____ Who does Lhe cooklng ln your household?
_____ uo you avold any food for culLural/eLhlcal reasons?
_____ uo you suspecL any foods don'L agree wlLh you? lf so,
whlch: _______________________________________
_____ Pave you recenLly changed your dleL? Pow? ________
_____ uo you ever have eaLlng blnges?
_____ WhaL do you blnge on? _____________________
_____ Pave you ever suffered from an eaLlng dlsorder?
________________________________________
_____ Are you excesslvely LhlrsLy?
_____ uo you drlnk unfllLered Lap waLer?
_____ uo you drlnk? lf so, whaL ls your usual alcohollc
drlnk? __________________________________
_____ Pow many glasses do you drlnk per week?
_____ 8oughly whaL percenLage of your food ls raw frulL
and raw vegeLables (l.e. uncooked, fresh)?
_____ uo you wash frulL and vegeLables before eaLlng?
_____ uo you frequenLly fry or roasL food aL hlgh
LemperaLures?
_____ uo you regularly eaL browned or barbecued
foods?
_____ uo you eaL olly flsh or shellflsh more Lhan 3 x a
week?
_____ uo you go ouL of your way Lo avold foods
conLalnlng preservaLlves or addlLlves?
_____ uo you avold foods whlch conLaln sugar?
_____ Pow many Leaspoons of sugar do you add Lo your
food/drlnks each day?
_____ uo you use salL ln your cooklng? ______________
_____ uo you add salL Lo your food?
_____ Pow many cups of Lea do you drlnk each day?
_____ Pow many cups of coffee do you drlnk each day?
_____ Pow many packeLs of 'lnsLanL' or fasL food do you
eaL each week?
_____ Pow many Llmes a week do you each chocolaLe
or confecLlonary?
_____ uo you normally eaL whlLe rlce/flour/bread or
brown?
_____ Pow many sllces of bread/rolls do you eaL
weekly?
_____ Pow many plnLs of mllk do you drlnk ln a week?
_____ Pow many Llmes weekly do you eaL red meaL
(beef, pork, lamb, game)?
_____ Pow many Llmes a week do you eaL whlLe meaL
(poulLry, Lurkey, flsh)?
CUk DIGLS1ICN
uo you experlence.
_____ lndlgesLlon (afLer food or beLween meals?)
_____ lndlgesLlon afLer faLLy food?
_____ uo you someLlmes suffer from bad breaLh
_____ uo you chew your food Lhoroughly?
_____ Pow many bowel movemenLs do you have ln 24
hours?
_____ uo you occaslonally use anLacld LableLs?
_____ Pave you noLlced any recenL change ln bowel hablL?
_____ uo your sLools floaL?
_____ 8owel movemenL shorLly afLer eaLlng?
_____ ConsLlpaLlon or hard-Lo-pass sLools?
_____ ularrhoea or 'urgency Lo go'?
_____ 8lood or mucus ln sLools?
_____ undlgesLed food ln sLools?
_____ Cenerally lnconslsLenL bowel movemenLs?
_____ lrequenL sLomach upseLs or sLomach paln?
_____ llaLulence or bloaLlng?
_____ nausea or vomlLlng?
_____ aln beLween Lhe shoulders or under Lhe rlbs?
_____ Anal lLchlng/ lrrlLaLlon?
_____ 1hrush or cysLlLls?
_____ Pave you ever had a sLomach upseL afLer forelgn
Lravel?
_____ uo any foods cause dlgesLlve problems? (whlch ones?)
_____ Are your sLools pale, mld brown, dark brown, black or
grey?
_____ uo you eaL on Lhe move/when sLressed?
_____ uo you frequenLly eaL under sLressful condlLlons or on
Lhe move?


CUk LNLkG LLVLLS
_____ uo you need more Lhan 8 hours sleep per nlghL?
_____ ls your energy less Lhan you wanL lL Lo be?
_____ uo you flnd lL dlfflculL Lo geL golng ln Lhe mornlng?
_____ uo you flnd lL dlfflculL Lo concenLraLe?
_____ uo you feel dlzzy or llghL-headed lf you sLand up
qulckly?
qulckly?
_____uo you suffer from unexplalned faLlgue or
llsLlessness?
_____ Are you rarely wlde-awake wlLhln 20 mlnuLes of
rlslng?
_____ uo you need someLhlng Lo geL you golng ln Lhe
mornlng, llke Lea, coffee or clgareLLe?
_____ uo you feel drowsy durlng Lhe day?
_____ uo you avold exerclse due Lo Llredness?
_____ WhaL Llme(s) of day ls your energy lowesL?
_____________________________________
_____ uo you geL dlzzy or lrrlLable lf you don'L eaL
ofLen?
_____ uo you use caffelne, sugar or nlcoLlne Lo keep
golng?



IMMUNL S1LM CnLCk
_____ Were you breasL-fed?
_____ uo you geL more Lhan Lhree colds a year?
_____ uo you flnd lL dlfflculL Lo shlfL an lnfecLlon (cold or
oLherwlse)?
_____ Are you prone Lo Lhrush or cysLlLls?
_____ uo you ofLen Lake anLlbloLlcs more Lhan Lwlce a
year?
_____ ls Lhere a hlsLory of cancer ln your famlly?
_____ Pave you ever had any growLhs or lumps
blopsled?
_____ uo you have an lnflammaLory dlsease such as
eczema, asLhma or arLhrlLls? _________________
_____ uo you suffer from hayfever?
_____ uo you suffer from allergy problems?
_____ Pave you had a ma[or personal loss ln Lhe lasL
year?
_____ uo you have a medlcally ldenLlfled food allergy or
lnLolerance?

WCMLN CNL
_____ Are you pregnanL? lf so, how many weeks? _______
_____ Are you Lrylng Lo become pregnanL?
_____ Are you breasL-feedlng aL presenL?
_____ Pow many chlldren have you had?
_____ Pave you had problems wlLh ferLlllLy?
_____ Pave you ever had a mlscarrlage?
_____ WhaL conLracepLlon do you use?
_____ Are you sLlll mensLruaLlng?
_____ Are you or have you been on P81?
_____ Are your perlods regular?
_____ Any bleedlng or spoLLlng ln beLween?
_____ Are your perlods parLlcularly heavy or palnful?
_____ uo you suffer from CCS, flbrolds, endomeLrlosls?
_____ Any known genlLo-urlnary condlLlons?
_____ Are you happy wlLh your sex drlve?

Menstruat|ng Women: please underllne lf you experlence:
pre-mensLrual bloaLlng, Llredness, lrrlLablllLy, depresslon,
breasL Lenderness, waLer reLenLlon, headaches. CLher?
Menopausa| Women: please underllne lf you suffer from: hoL
flushes, lnsomnla, osLeoporosls, mood swlngs, depresslon,
vaglnal dryness. CLher?

MLN CNL
_______ uo you experlence mood swlngs or depresslon?
_______ Loss of sex drlve?
_______ Loss of moLlvaLlon and drlve?
_______ Any known genlLo-urlnary condlLlons?
_______ lerLlllLy problems?
_______ roblems achlevlng or malnLalnlng an erecLlon?
_______ lrequenL or dlfflculL urlnaLlon?
_______ rosLaLe problems
_______ Wake aL nlghL Lo urlnaLe
_______ ulfflculL Lo sLarL or sLop urlne sLream
_______ aln or burnlng when urlnaLlng

nLAL1n CAkL kCVIDLkS
ls Lhls your flrsL vlslL Lo a nuLrlLlonal 1heraplsL?

Pow dld you flnd ouL abouL me?

C's name

Address:


hone:

Are any oLher LheraplsLs/cllnlcs lnvolved ln your care?
lease llsL:




l have dlsclosed all Lhe relevanL lnformaLlon appllcable
Lo Lhls consulLaLlon and my healLh sLaLus aL Lhls polnL ln
Llme. l consenL for Lhe lnformaLlon provlded Lo be used
by my nuLrlLlonal 1heraplsL and for my LheraplsL Lo llalse
wlLh approprlaLe healLh professlonals.



Slgned_______________________ uaLe _____________


CUk kCU1INL
lease record your rouLlne across 2 work or week days and 1 weekend/day off.
Day 1 Day 2 Day off
Wake up t|me



Get up t|me



Work day start t|me



Work day breaks (tota| t|me)



Work day end t|me



1|me spent trave|||ng



1|me spent exerc|s|ng




1ype of exerc|se





Lxerc|se t|me of day



1|me spent re|ax|ng



1ype of re|axat|on




Cther |e|sure act|v|ty


Cther rout|ne


Lnergy |ow t|me


Cvera|| mood




Go to bed t|me



Go to s|eep t|me



Un|nterrupted s|eep?
?/n


?/n ?/n










lease choose 2 falrly Lyplcal week days and a weekend or 'day off' and record as much as you can abouL your eaLlng,
sleep and lelsure paLLerns on Lhe page below. lease glve as much lnformaLlon as posslble - home cooked or noL, brand
names, fresh, packaged, whole, reflned, organlc eLc. Lo help your nuLrlLlonal LheraplsL Lo bulld an accuraLe plcLure of
your llfe
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1erms of Lngagement Nutr|t|ona| 1herap|st and C||ent

What |s Nutr|t|ona| 1herapy?
nuLrlLlonal 1herapy (n1) ls Lhe appllcaLlon of nuLrlLlon sclence ln Lhe promoLlon of healLh, peak performance and
lndlvldual care. nuLrlLlonal Lherapy pracLlLloners use a wlde range of Lools Lo assess and ldenLlfy poLenLlal
nuLrlLlonal lmbalances and undersLand how Lhese may conLrlbuLe Lo an lndlvldual's sympLoms and healLh concerns.
n1 ls recognlsed as a complemenLary medlclne and ls relevanL for lndlvlduals wlLh chronlc condlLlons, as well as
Lhose looklng for supporL Lo enhance Lhelr healLh and wellbelng.

racLlLloners conslder each lndlvldual Lo be unlque and recommend personallsed nuLrlLlon and llfesLyle
programmes raLher Lhan a 'one slze flLs all' approach. racLlLloners never recommend nuLrlLlonal Lherapy as a
replacemenL for medlcal advlce and always refer any cllenL wlLh 'red flag' slgns or sympLoms Lo Lhelr medlcal
professlonal. 1hey wlll also frequenLly work alongslde a medlcal professlonal and wlll communlcaLe wlLh oLher
healLhcare professlonals lnvolved ln Lhe cllenL's care.

1he Nutr|t|ona| 1herap|st (N1) requests that the C||ent notes the fo||ow|ng -
- 1he degree of beneflL obLalnable from nuLrlLlonal 1herapy may vary beLween cllenLs wlLh slmllar healLh problems
and followlng a slmllar nuLrlLlonal 1herapy programme.

- nuLrlLlonal advlce wlll be Lallored Lo supporL healLh condlLlons and/or healLh concerns ldenLlfled and agreed
beLween boLh parLles.

- nuLrlLlonal LheraplsLs are noL permlLLed Lo dlagnose, or clalm Lo LreaL, medlcal condlLlons.

- nuLrlLlonal advlce ls noL a subsLlLuLe for professlonal medlcal advlce and/or LreaLmenL.

- SLandards of professlonal pracLlce ln nuLrlLlonal 1herapy are governed by Lhe 8An1 Code of rofesslonal racLlce.

1he C||ent understands and agrees to the fo||ow|ng
?ou are responslble for conLacLlng your C abouL any healLh concerns.

- l glve permlsslon for you conLacL my C regardlng any agreed aspecLs of my case: LS NC

- lf you are recelvlng LreaLmenL from your C, or any oLher medlcal provlder, you should Lell hlm/her abouL any
nuLrlLlonal sLraLegy provlded by a nuLrlLlonal LheraplsL. 1hls ls necessary because of any posslble reacLlon beLween
medlcaLlon and Lhe nuLrlLlonal programme.

- lL ls lmporLanL LhaL you Lell your nuLrlLlonal LheraplsL abouL any medlcal dlagnosls, medlcaLlon, herbal medlclne,
or food supplemenLs, you are Laklng as Lhls may affecL Lhe nuLrlLlonal programme.

- lf you are unclear abouL Lhe agreed nuLrlLlonal Lherapy programme/food supplemenL doses/Llme perlod, you
should conLacL your nuLrlLlonal LheraplsL prompLly for clarlflcaLlon.

- ?ou musL conLacL your nuLrlLlonal LheraplsL should you wlsh Lo conLlnue any speclfled supplemenL programme for
longer Lhan Lhe orlglnal agreed perlod, Lo avold any poLenLlal adverse reacLlons.

- 8ecordlng consulLaLlons uslng any form of elecLronlc medla ls noL allowed wlLhouL Lhe wrlLLen permlsslon of boLh
Lhe nuLrlLlonal 1heraplsL and Lhe CllenL.
We understand the above and agree that our profess|ona| re|at|onsh|p w||| be based on the content of th|s
document. We dec|are that a|| the |nformat|on we share dur|ng th|s profess|ona| re|at|onsh|p |s, to the best of
our know|edge, true and correct.

Name: _______________________________________ Date: ________________

S|gnature: ____________________________________

Nutr|t|ona| 1herap|st: __________________________ Date: ________________
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