Health & Nutritional Questionnaire - Nutrition | Nutritionist | Paula Duggan Nutrition| Balance Nutrition

Name*

First Last

Email*

Phone*

Address

Age*

Gender*

Female
Male

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?*

Have 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?*

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, Constipation

Are 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*

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

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

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.

Comments

This field is for validation purposes and should be left unchanged.