Nutritional Therapist Contact Form

To ensure the maximum benefit of Nutritional Therapy, it is important that your information is accurate and up-to- date. If you notice any changes to your health, begin taking new prescriptions, etc., please notify your Nutritional Therapy Practitioner (NTP) or Nutritional Therapy Consultant (NTC) as soon as possible. It is also your right as a client to access, update, or delete your records at any time. Though NTPs and NTCs are not HIPAA regulated entities, the Nutritional Therapy Association, Inc. (NTA) is committed to protecting client privacy and requires students and graduates to uphold the privacy best practices and the policies laid out in the U.S. Standards for Privacy of Individually Identifiable Health Information. Please see the Disclaimer for further details.

Name

Email *

Date of Birth *

Include place of birth.

Blood type

if known

Age, Height, Weight *

Gender

Nutritional Goals or Health Concerns *

List your TOP 3

What would you like to gain from Nutritional Therapy What are your personal health goals? *

What time do you usually go to bed and when do you normally wake up? *

Estimate total hours.

Rate your sleep quality. (1 Low - 10 High) *

How do you feel when you wake up? *

How much water do you drink per day?

Estimate it in Cups or Ounces

Do you drink caffeinated drinks (e.g. coffee, black tea, soda, etc.)? *

If yes, how much per day on average? Estimate in Cups or Ounces.

What were your current eating habits? (List typical types of food below) *

What % of your food is home-cooked? What percentage is not? *

Give a ratio - 80/20 = 80 percent home cooked and 20 percent is not.

In your opinion, what do you think are the three least healthy foods you eat each week and why? *

Conversely, what do you think are the three healthiest foods you eat each week and why? *

Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, prescription or non-prescription medications, aspirin, laxatives, diet pills, or any other supplements? *

If yes, please list.

Do you have any known allergies to medications or herbs? *

If yes, please list.

Are you currently under a practitioner’s care for a specific issue? *

If yes, please list, include contact info if possible.