Nutritional Therapy Clinic-Questionnaire

Welcome and thank you very much for booking an appointment with our Nutritional Therapy student clinic.

To prepare you and our students for your appointment, we ask you to complete two pre-appointment forms online.

The forms should be completed and submitted no later than 2 weeks before your appointment is due. This will help our students to thoroughly prepare and will also speed up the consultation process.

There are two links on this page. The first one is a general pre-appointment form which will take approx 30 minutes to complete. Underneath you will find a link to a 3-day food diary. Again please complete as best you can and submit both forms no later than 2 weeks before your appointment is due.

For protection of your confidentiality we ask you to use your Booking Reference number instead of your name.

For further help or information phone 01 2723003 Mon-Fri 9am-5pm.


The final section of the Food Diary form consists of a Terms of Engagement form which we will ask you to agree to.

The text is below, please read so that you will be familiar with the content when you are asked to sign.

Thank you


Nutritional therapy is an individual centered approach to healthcare that employs assessment and intervention using nutritional, lifestyle based and related health sciences in order to assist the individual to optimise his or her physiological (internal processes), emotional, cognitive and physical function. This is different to the diagnosis and treatment of medical conditions which is solely carried out by doctors.

The Nutritional Therapist

The therapist will assess the individual’s general health, family history, dietary habits, digestive function and lifestyle.
The therapist may recommend specific functional tests. A tailored suitable dietary and lifestyle plan will be identified and agreed between both parties.
We abide by the NTOI (Nutritional Therapists of Ireland) Code of Professional Practice.

The Client

You are responsible for contacting your GP about any health concerns.
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. Likewise, if you are receiving treatment from your GP or any other medical provider, you should tell them about any nutritional strategy provided by the Nutritional Therapist.

It is imperative that you contact your Nutritional Therapist if you are unclear about any aspect of the programme. The Nutritional Therapist will provide clarification on any issues you may have. You are advised to report any concerns about nutritional therapy promptly to your Nutritional Therapist for discussion and action.
You must contact your Nutritional Therapist should you wish to continue any specified supplement programme for longer than the agreed period, to avoid any potential adverse reactions.

Discussing your expectations

We will discuss your expectations and tell you whether we think they are realistic. It is important to us that you understand at all times what is happening in your case. To help prevent any confusion or stress on your part, we will give you general information and explain any procedures regarding your programme as it progresses.


We may share your sensitive information with third parties to support your ongoing healthcare.  If we do not receive this consent from you, we will not be able to coordinate your healthcare with that provided by other providers which means the healthcare provided by us may be less effective.

Please tick the appropriate boxes to confirm your consent: (Consent will be discussed with you in advance of any contact being made.)

I consent to my sensitive information being shared with testing companies if appropriate.

I consent to my sensitive information being shared with my GP if appropriate

You can withdraw your consent to the above at any time by emailing

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