Nutritional Therapy Questionnaire

Thank you for your payment, an email receipt has been sent to you.

Please read the instructions below, as this will help complete the Functional Health Check Questionnaire.

This is an in-depth questionnaire. It would be a good idea to allow about 20 minutes to fill it out.

Before starting the questionnaire please gather the following:

  • Past/present medication/supplements names/dosages
  • GPs address and phone number
  • Medical supporting documents, like operations, treatments etc

The form is easy to navigate around, as it is broken down into Zones, and you can jump from one Zone to another, by selecting the Zone number. All Zones need to be completed to the best of your ability, if your not sure about anything, there are comment/notes areas in each Zone.

On one part of the form there are questions about your family’s’ health history. You may not have this information, don’t worry just fill in what you know.

The questionnaire doesn’t expire, so you can leave it open and come back to it. But please don’t close the browser window or tab or you will have to start over again.

So get yourself a nice cup of tea, sit back, relax and let’s begin.


This is an encrypted questionnaire to protect your data input, on completion the questionnaire is sent to me via encrypted email, this is for your safety and security. All your data will be kept safe and secure; it will not be shared or sold to anyone. Kali Health practises client confidentiality and your data is treated as such.

Please always make sure you see the green padlock on your browser address bar, this will indicate the connection is secure and encrypted. It looks like this:

I look forward to receiving your completed questionnaire and beginning your health journey!

If you have any questions or problems with this questionnaire please send me a message below.

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Data Protection Reg. No.: Z3426317