By completing this intake form you give permission to share your personal data with NutriSwitch. This data will remain within NutriSwitch and will never be shared with third parties. As soon as the intake form is received, it will be removed from the server by NutriSwitch.

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Personal details

We would like to know how you found us
Contact Details
The number we can reach you on
Background Information
In kilograms
In centimeters
Medical Info
Whom has treated you.
Medical details family
Hereditary disorders  (heart- and cardiovascular disease, reumatoid arthritis, cancer, Diabetes, skin disorders) and non-hereditary disorders.



Intake & excretion

Indicate your preference of flavours
Bowel movement


Kindly tick the applicable disorders only. If you have had current disorders in the past as well tick both boxes.

Stomach / intestines
Heart and vascular issues
Respiratory system
Skin health
Urinary tract
Colour, odor, quantity
Female Health
Sore breasts, sugar cravings, irritable, tired before menstruation
if so, at what age?
Mental Condition
Muscles and joints
Please describe as chronologically as possible:

Medical History

List your diseases and illnesses you have experienced in your life in chronological order
what, how, when, how often?


Nutrition, Supplements & Medication
List the foods and drinks you consume on an average day
List all the vitamins and minerals you take (type, brand, dosage)
List any medication you take (type, brands, dosage)
Yes, I consent to NutriSwitch collecting my data (see our privacy statement what we do with your data).
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