Nutritionist Form | in:spa retreats

Storage of Information*

I confirm that the client has given permission for their Nutrition form to be completed and stored

Please check this box if the client is happy for in:spa to store their Nutrition form for reference on their future retreats with us and passed on to their next nutritionist. Please do not complete and submit this form if not.

Client Name*

Client Email*

Retreat*

Date of Consultation*

Nutritionist*

Symptoms

Please tick any symptoms that the client experiences

Digestive Health

Female Health

Male Health

Prostate problems
Frequent urination
Hair loss
Loss of drive/motivation

Energy, Mind & Mood

Immune Profie

Frequent infections
Frequent antibiotics
Glandular fever
Recurrent cystitis
Recurrent thrush
Cold sores
Bleeding gums
Autoimmune disease
Poor recovery

Heart health

Skin health

Movement profile

Joint pain or arthritis
Muscle cramps
Regular cardio exercise
Regular weights/toning
Reguler yoga/pilates
Consider yourself fit

Other Health Issues*

Goals*

Client Plan

Comments on current diet, medications & Supplements*

Brief comment on client's current diet and what medications and supplements they are currently taking?

Nutritionist recommendations

Recommended supplement plan

Please note: - Always take supplements with food unless advised otherwise; this improves absorbability of the nutrients - You may notice your urine turns bright yellow. This is harmless and is due to normal utilisation of vitamins. - If your doctor advises you to take any medications or makes changes in your medications, please let your nutritionist know so that they can review your supplements in the light of these changes. - You can order supplements through the following places (and get 10% OFF using the code below) + NutriCentre: 08456027197 (discount code - ZZINS010) + The Natural Dispensary: 01453757792/www.naturaldispensary.co.uk (discount code - RETREAT10)

Nutritionist email address

Add your email address here if you would like to receive a copy of the form.