Please rate your motivation on a scale of 0 to 10 (0=low; 10=high):

The questionnaire below is used to measure changes in health outcomes following health recommendations. Recommendations should be followed for a period of 2-3 months, this enables us to identify any improvements or additional requirements to make appropriate recommendations as well as tracking effectiveness of recommendations. After this time, please contact HealthQ@cytoplan.co.uk to review your program. 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. Write them on the lines.

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

Health Questionnaire Service: This free service, which is available from our in-house Registered Nutritional Therapist, is offered to our customers as we recognize the importance of diet, lifestyle and choosing appropriate supplements as important to support health improvement. Offering this no obligation service is also in line with our charitable objectives; we are wholly owned by a charitable foundation that supports environmental and health improvement projects globally. If you complete and return the attached questionnaire, our Registered Nutritional Therapist will send you some written diet and supplement recommendations to support your health goals. However, please be aware that as a postal questionnaire we are 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 2 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.

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.