Email
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Phone
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(###)
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Date of Birth
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MM
DD
YYYY
Occupation
Are you pregnant or breastfeeding?
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Have you been medically diagnosed with an eating disorder?
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Have you been medically diagnosed with any of the following? If so please list.
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Diabetes, Irritable bowel syndrome, Crohn's disease, Cancer, Renal disease, Chemical sensitivity or infertility?
Have you had recent Gastric Bypass surgery? (past 2 years)
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Do you have diagnosed chronic gastrointestinal tract issues such as ulcerative colitis, bowel obstruction, diverticulitis or bowel resections?
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Is your BMI (body mass index) below 18 or over 40?
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Do you have high chloesterol?
Do you experience bloating or excessive flatulence regularly?
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Do you experience problematic bowel motions? Eg: diarrhoea, constipation, sore to pass, abnormal colours, faecal urgency)
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How regular are your bowel eliminations?
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2-3 times day
Daily
Every 2-3 days
Twice a week
Every 7 days or longer
Do you believe you suffer from chronic low energy levels?
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Have you been formally diagnosed with any food allergies?
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If yes, please specify food allergy, diagnostic tool and approximate diagnosis date.
Do you suspect you might have a food allergy?
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If yes, please explain hy you think you may have an allergy and to what food/s.
How many glasses of water do you drink per day?
0-1
2-4
4-6
8+ glasses per day
Alcohol - How many standard drinks would you consume in an average week?
None
1 -2 drinks per week
3-4 drinks per week
5-7 drinks per week
7-10 drinks per week
10+ drinks per week
Caffeine - How many caffeinated drinks do you consume per day?
None
1 - 2 per day
3 - 4 per day
4 - 6 per day
6 or more per day
Do you smoke or have you previously smoked?
Yes
No
Smoked previously
Please describe your current meal habits. How many meals do you eat a day? Do you skip meals? Do you have particular eating pattern you follow eg: intermittent fasting?
Are you vegan, vegetarian or have any other dietary preferences or restrictions?
Are you currently taking any supplements or vitamins? If yes please list type and dose.
Have you tried any diet or approaches in the past? If YES, what methods or changes did you try? Why did you discontinue this approach?
Do you regularly suffer from any cravings?
Do you feel you have a 'bad' relationship with food?
Any significant weight changes in the last 6 months?
Would you like your weight to be different? If so, how?
How is your sleep? (How many hours? Do you wake up? Why? etc...)
Do you suffer chronic stress or have experienced extended periods of stress?
Do you experience depression, anxiety or weepiness? Please provide details:
Do you experience frequent colds or infections?
Do you experience brain fog or inability to concentrate?
Do you have dry hair or brittle nails?
Do you have asthma or allergies?
Do you have (or have had) any major illnesses, conditions or surgeries that may affect you day to day health?
Menstrual Cycle - if applicable. Do you have regular periods? Are they symptomatic, painful, etc... please give brief explanation.