The Cytoplan questionnaire is a comprehensive set of questions that requires you to submit information across the following 6 categories. The questions should take you between 10-15mins to populate and once submitted it will be reviewed by our in-house nutritionist who will be in contact with you within 5 working days.
Recent Consultations: Please provide approximate dates and details of any consultations:
Has your child now or in the past experienced any of the following? Tick if the answer is YES
Prescribed Medicines: Please list all medications your child is currently taking and include dose. This information is important to enable us to suggest safe and appropriate nutritional supplements for your child.
Family Medical History. Please provide details below of family health conditions. e.g. Angina, Alzheimer’s, Arthritis, Asthma, Blood pressure, Cancer, Dementia, Diabetes, Heart disease, Lung disease, Osteoporosis, Parkinson’s disease, Stroke.
How many slices of bread does your child eat per week of the following ?
How many portions /week does your child eat of the following?
Please insert approximate number.
Fluids -Cups per day of:
Cans/Glasses per day of:
How motivated are you / your child to change the way you eat and to experiment with new foods?

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

Please write down all the foods and drinks your child consumes over a 3 day period, include 1 weekend day. Please complete as accurately and honestly as possible.

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.


I understand the above and agree that the health questionnaire service provided by Cytoplan Ltd will be based on the content of this document. We declare that all the information we share on this health questionnaire is confidential and, to the best of our knowledge, true and correct.

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