Consult preparation

Intake questionnaire

The better I understand your situation, the more we will get out of your consultation. Please take a moment to answer these questions. Everything you provide will remain confidential between us.

1. About you

First and last name * Email address * Phone (in case the video call fails) Order number Which consultation did you book? * Age * Gender Height and weight (optional)

2. Your question What is the main goal of this consultation? * Which complaints do you have and since when? * How much do they bother you day to day? (1 = barely, 10 = a lot) What have you already tried (diet, herbs, cleanses, treatments) and what was the effect? When is the consultation a success for you? What should be different in 3 months?

3. Health and medication

Important: some herbs interact with medication (e.g. blood thinners, blood pressure, diabetes or thyroid medication, antidepressants, the pill). Please fill this in as completely as possible.

Do you take any medication? Which ones and what dose? * Are you being treated by a doctor or specialist? If so, for what? Diagnoses or conditions (current or past) Surgery or hospital stays in recent years Which supplements, herbs or cleanses are you taking now? Allergies or sensitivities (food, herbs, medication)

Pregnant, trying to conceive or breastfeeding? Do you have recent blood test results?

4. Diet How would you describe your diet? *

Do you eat animal products? How often?

Red meat (beef, lamb, pork)Chicken or other poultryFish or seafoodDairy (milk, cheese, yoghurt)Eggs

What do you eat and drink on a normal day? (breakfast, lunch, dinner, snacks)

How much water do you drink per day? How many meals do you eat per day? Coffee or black tea Soft drinks, sweets or sugary snacks Fast food or ready meals Alcohol Do you smoke or use other substances? Do you cook yourself?

Any experience with alkaline eating, Dr. Sebi, fasting or cleanses?

5. Body and lifestyle

How many hours do you sleep on average? Do you wake up rested? Energy during the day (1 = exhausted, 10 = very fit) Stress (1 = relaxed, 10 = a lot) How often do you have a bowel movement? How much do you move or exercise per week?

Do you suffer from bloating, gas, heartburn or nausea? Skin: eczema, acne, itching or dry skin? For women: is your cycle regular? Any PMS, painful periods or menopause symptoms? What causes you stress or drains your energy at the moment?

6. Practical

Monthly budget for herbs and supplements How did you find Ital Natty?

Anything else you'd like to share, or a specific question for the consultation?

It takes about 10 minutes. Ideally fill it in at least 24 hours before your consultation.

Intake questionnaire

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