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Initial Consultation Form Information & Questions

Thank you for choosing Nayamana Nutrition. Please take a moment to review the following information and answer the questions below. You may complete the form by typing the answers or by writing. Please email to info@nayamananutrition.com when completed

Which consultation format would you prefer?

Have you had any previous nutritional therapy consultations?

Yes
No

How did you hear about Nayamana Nutrition?

Preferred days and times for your consultation?

What are your main health goals?

Any dietary restrictions or preferences?

Health Questionnaire

Full Name

Date of Birth

Age

Height

Weight

Contact Details

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

Health Information

Current Health Issues

Current Medications (including dosage):

Vaccination History

Additional Information

Please use this space to note any other issues or concerns you would like to discuss during your consultation

1. The information you provide will be used solely for:

Providing nutritional therapy services
Maintaining appropriate clinical records
Contacting you regarding your consultations and care

2. Your personal data will:

Be stored securely
Never be shared with third parties without your explicit consent
Be retained only for as long as necessary for your care
Be processed in accordance with current data protection regulations

3. You have the right to:

Access your personal data
Request corrections to your data
Request deletion of your data (where applicable)
Withdraw consent at any time

For our full privacy policy or any questions about how we handle your data, please contact us.

Declaration

I confirm that the information provided is accurate and complete to the best of my knowledge.

Signature

Clear Signature

Embrace the Power of Natural Healing

Initial Consultation Form

Initial Consultation Form Information & Questions

Health Questionnaire

Contact Details

Health Information

Nayamana Nutrition

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