Name* First Last Email* Phone*AddressAge*Gender* Female Male What is your occupation?* Weight (kg)* Height (cm)* Weight goal* Maintenance Loss Gain What nutrition & health goals do you have?*Do you exercise?* Yes No Tell me what type of exercise you do & how often you exercise.*How did you hear about me?*Google searchFollow me on social mediaFacebook / Instagram AdRecommendation from Friend / familyReferral from a Health care professionalWord of mouthPoster / Print mediaHave you any particular medical conditions?*List any medications or supplements you are taking? Please explain, what each is for.*Is it possible you may be pregnant?* Yes No Are you breastfeeding?* Yes No Do you drink?* Yes No How many units of alcohol do you drink in a week?*0-23-45-78+Do you smoke?* Yes No Do you or have you ever had an eating disorder?* Yes No Can you tell me more about it please, what type of disorder, is it active / when was it last active?*Have you any food allergies/intolerances?* Yes No Tell me more about allergy/intolerance. Eg. Symptoms, How it was diagnosed? Has it improved? Are you still excluding said food/foods from your diet?Have you any digestive problems? E.g. IBS, ConstipationAre you a vegetarian or vegan?* Yes No Tell me more. Are you vegetarian or vegan. What made you decide to become veg/vegan? When did you become veg/vegan?What kind of eater are you? Foodie Plain Binge eater Fussy Lack of interest in healthy food You can select more than one but try to select the ones that BEST describe you!Is there any food/ food group you don’t/won't eat? E.g. dairy/eggs/fish*Which of the following drinks would you regularly drink? Tea/Coffee Lattes/cappucinos etc Milk Juice Smoothies Protein shakes Sports drinks Cordial No added sugar cordial Fizzy drinks regular Diet fizzy drinks You can select more than one but try to select the ones that BEST describe you!What are your pitfalls/challenges? You can select more than one choice.* Night-time eating Lack of organisation Work environment is an issue Social Life / Eating out Lack of interest in healthy food Lack of interest in cooking Home environment Eat too much junk Binge eating All or nothing approach What concerns do you have about your diet?*Is there anything in particular you would like to learn about from a nutritional perspective?Describe a typical day to me – your schedule, wake, travel, work, family, social, hobbies, exercise, sleep.*RECALL EVERYTHING YOU ATE & DRANK YESTERDAY*Give as much detail as possible 1.Time 2.Food/Drink 3.Description 4.Portion 5.Brand RECALL EVERYTHING YOU ATE & DRANK TODAY*If these 2 days do not represent your regular diet, describe a typical day to me food wise.Terms & Conditions* Click here to agree to our Privacy Policy Communication* Sign-up to receive information on Tips / Recipes / future programs / Special Offers / Workshops *If you tick "No", I will dispose of all your personal data on completion and if we are to work together again, I will need you to complete this booking form again.* Tick to consent to your personal data being kept on file *If you tick "No", I will dispose of all your personal data on completion and if we are to work together again, I will need you to complete this booking form again. EmailThis field is for validation purposes and should be left unchanged. Δ
