Pre-Consultation Nutritional Health Questionnaire

Please try to ensure you answer each question as accurately as possible to the best of your knowledge. Where you are not sure of the answer, please put Not sure or N/S.

Next Step: Health Profile

Health conditions / symptoms you are seeking support for

How long have you had this?

In case we need to contact you regarding any information in your form please provide your preferred contact email address (unless requested otherwise)

We will research any areas necessary and respond via telephone, email or during your consultation appointment where booked. Please note, your health questionnaire support or recommendations are not intended to replace medical advice. If you have health concerns it is important to obtain a medical diagnosis for your symptoms.

Please provide approximate dates and details of any consultations

G.P.

Medical Consultant

Practitioner / therapist

Please tick the box next to any of the following that apply to you.

Have you now or in the past experienced any of the following? Tick if the answer is YES

Condition:

Previous Step: Personal Information

Next Step: Prescribed Medicines

Please list all medications you are currently taking and include dose. This information is important to enable us to suggest safe and appropriate nutritional supplements for you.

Please continue in the space below if needed.

Please list all supplements that you are taking currently, dose and brand names

Please list any recently discontinued medications or supplements?

Please provide details below of family health conditions. e.g. Angina, Alzheimer's, Arthritis, Asthma, Blood pressure, Cancer, Dementia, Diabetes, Heart disease, Lung disease, Osteoporosis, Parkinson's disease, Stroke.

Please list any foods you exclude from your diet. e.g. dairy, eggs, soy, wheat, gluten

Have you taken any food allergy/intolerance tests?

Please insert approximate number

Cups per day of

Cans/Glasses per day of

Number per day

Alcohol

Previous Step: Health Profile

Next Step: Food Diary

Please list all the foods and drinks you consume over a 3 day period, include 1 weekend day. Please complete as accurately and honestly as possible.

Previous Step: Prescribed Medicines

Next Step: Terms & Conditions

The assessment tool below is used to measure changes in health outcomes following health recommendations or your tailored program. It is recommended to complete a follow up assessment after 6-8 weeks, which enables us to identify any improvements or additional requirements to make appropriate recommendations as well as tracking effectiveness of recommendations already received. This data may be used for case studies, which will be completely anonymous and will not be used without permission of the client.

Choose one or two symptoms (physical or mental) which bother you the most. Type them on the lines.

Now consider how bad each symptom is, over the last week, and score it by highlighting your chosen number.

Now choose one activity (physical, social or mental) that is important to you, and that your problem makes difficult or prevents you doing.

Score how bad it has been in the last week.

How long have you had Symptom 1, either all the time or on and off?

Health Consultation: The initial scan and consultation, which is available via one of our Certified Nutritional Therapists, will take place online or at one of our dedicated centres. Our Lifestyle Change Programs are offered to our clients as we recognize the importance of diet, lifestyle change and choosing appropriate supplements to support health improvement and develop better habits. Providing this no obligation service is also in line with our group core vision of promoting Freedom Through Wellbeing while developing a global community of health-conscious ambassadors, who have attained freedom from ill health and are now sharing their experience to empower others.

Once you complete and submit this questionnaire, our Certified Nutritional Therapist will review the information provided and make diet and supplementary recommendations to support your health goals. However, please be aware that when conducting online or international consultations we are sometimes limited in the suggestions and support we can provide.

The Nutritional Therapist requests that the client notes the following:

• The degree of benefit obtainable from the recommendations may vary between clients with similar health problems and following a similar programme.
• Nutritional advice will be tailored to support health conditions and/or health concerns identified on the health questionnaire.
• We are not permitted to diagnose, or claim to treat, medical conditions.
• Nutritional advice is not a substitute for professional medical advice and/or treatment.

The client understands and agrees to the following:

• You are responsible for contacting your GP about any health concerns.
• If you are receiving treatment from your GP or any other medical provider you should tell him/her about any nutritional strategy provided by a Nutritional Therapist. This is necessary because of any possible reaction between medication and the nutritional programme.
• It is important that you tell your Nutritional Therapist about any medical diagnosis, medication, herbal medicine or food supplements you are taking as this may affect the nutritional programme.
• If you are unclear about the agreed programme / food supplement doses / time period, you should contact your Nutritional Therapist promptly for clarification.
• You must contact your Nutritional Therapist should you wish to continue any specified supplement programme for longer than 3 months, to avoid any potential adverse reactions. In any case we recommend a regular review of supplements to ensure they remain appropriate for your needs.
• You are advised to report any concerns about your programme promptly to your Nutritional Therapist for discussion / action.
• Please note we do recommend that all supplements are taken at different times of the day to any prescribed medications.

• Mobile Phones and Metal Objects: All scan and consultation appointments involve a Non-invasive Bio Energy Scan that reads the electro-magnetic frequencies from your body cells. Please ensure all mobile telephones, electronic equipment and metal objects such as bracelets, watches, necklaces and earrings are removed prior to commencing your scan.
• Reports: Reports are produced instantly, evaluated and discussed in full during your consultation. Requests for a copy of the report (if required) must be made on the day or submitted in writing following your scan and consultation.
• Young Children: An adult MUST accompany a child aged 13 and under. ALL children MUST be aged 3 or over to be eligible for a scan. All children aged 14-17 are classed as young adults and will be charged the adult price.
• Home Visits: Home visits will be considered under special circumstances and where possible, are subject to a premium payable in advance. (£250 within London, £280 within the M25, £300 for outside London).
• Payments: All payments must be made in advance, with FULL PAYMENT due at the time of booking to confirm and secure your appointment. Payments can be made via debit / credit card or bank transfer to the account details provided.
• Late or Missed Appointments: If you are running late for an appointment you must inform us of your estimated arrival time as soon as possible. If you miss your scheduled appointment an additional appointment can be scheduled for you, up to a maximum of two (2) times, provided you inform us in advance
• Cancellation and Refunds: Please be aware consultation appointments and subsequent purchases will NOT be eligible for refunds. If you cancel your appointment or purchased product/program at any time NO REFUND will be given however, exchanges or adjustments may be offered.
• DISCLAIMER: Your bio energy scan and consultation will provide an extensive insight into your health with general information and recommendations for improvement from a nutritional perspective. Recommendations should not replace or be a substitute for medical advice If you think you may be suffering from any medical condition you should seek immediate medical advice from your G.P.

We would always recommend you discuss any dietary or supplemental concerns or changes you wish to make with your G.P. Medication should never be discontinued or dosage amended without your G.P.'s prior knowledge and agreement.

• I understand the above and agree that the Nutritional Consultation and recommendations provided by Mi Healthcare Group Ltd will be based on the content of this document and any additional test/scan data derived. We declare that all the information we share on this health questionnaire is confidential and, to the best of our knowledge, true and correct.
• I have read and agree to the terms and conditions

Previous Step: Food Diary