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Name *

First

Last

Email *

Mobile Phone Number *

Date of Birth (Day/Month/Year) *

Emergency Contact Name *

Emergency Contact Number *

Street Address *

City *

Post Code *

Please list any medical conditions you currently experience:

What are your main issues of concern today? *

Please list your health & wellness goals *

Have you visited a nutrition/dietician before today? *

• Yes
• No

Do you have a family history of disease/allergies? i.e. heart disease, diabetes, asthma, cancer etc. *

• Yes
• No

If yes, please detail who (i.e. father, grandfather) and the illness

What is your normal blood pressure? *

What is your current weight? *

What is your height? *

Is your weight stable / increasing or decreasing? *

What is your waist circumference? *

What is your hip circumference? *

Are your stools (please choose most frequent) *

• Hard to pass
• Sausage shaped, but lumpy
• Sausage shaped, with cracks on surface
• Sausage shaped, smooth & soft
• Soft blobs with clear cut edges (easy to pass)
• Fluffy pieces with ragged edges, mushy
• Watery, no solid pieces (liquid)

How many alcoholic standard drinks do you consume per week? *

• 1-3
• 4-8
• More than 8

Do you smoke cigarettes or vape? *

• Yes
• No

Are you currently taking any medications? *

• Yes
• No

If yes, please list below:

Have you ever suffered an eating disorder i.e. anorexia/bulimia? *

• Yes
• No

Do you often have digestive disturbances? i.e. bloating, gas, belching, diarrhea, constipation? *

• Yes
• No

If yes, please describe how often, how long symptoms tend to last and is it after specific foods i.e. wheat, dairy etc.

Do you feel excessive fullness after you eat? *

• Yes
• No

Have you ever been diagnosed with anemia or hemochromatosis? *

• Yes
• No

If yes, please detail when and current status:

Have you been clinically diagnosed with a food intolerance / sensitivity? *

• Yes
• No

If yes, please describe what has been diagnosed by who and when:

Do you suffer from tiredness or painful joints? *

• Yes
• No

If yes, please describe below:

Do you suffer from Asthma, or sinus related issues? *

• Yes
• No

If yes, please describe below:

Do you have a history of drug or alcohol abuse? *

• Yes
• No

Is your stomach upset by greasy foods? *

• Yes
• No

Do you become sick or easily hungover from drinking wine? *

• Yes
• No

Are you sensitive to NutraSweet or any other sweetner? *

• Yes
• No

Do you suffer from chronic fatigue or fibromyalgia? *

• Yes
• No

Do you often binge or have uncontrolled eating? *

• Yes
• No

If yes, please describe below:

Do you eat regularly throughout the day? i.e. Breakfast, snack, lunch, snack, dinner? *

• Yes
• No

If no, please describe how often you eat below:

Are you irritable before meals or shaky if meals are delayed? *

• Yes
• No

If yes, please describe below:

Do you often yawn or feel tired mid-afternoon? *

• Yes
• No

Do you often crave coffee or sugar during mid-afternoon? *

• Yes
• No

Have you been told you have high cholesterol? *

• Yes
• No

Are you pregnant or have you given birth within the last 12 months? *

• Yes
• No

Have you been told that you have high blood sugar? *

• Yes
• No

What time do you eat your first meal of the day? *

• Yes
• No

Do you have a history of dieting? *

• Yes
• No

How often do you weigh yourself?

• Daily
• Every other day
• Weekly
• I don't... what are scales?

Do you feel a negative association between food and weight? *

• Yes
• No

Do you view your body positively? *

• Yes
• No

What is the main reason you seek assistance with your nutrition? *

Are there any foods you don't like or omit from your diet, if yes, please detail why below: *

Have you had any major health concerns over the past 10 years, including surgeries? If yes, please detail below: *

Is there anything else you would like to details of importance regarding your nutrition? If so, please write below:

How did you hear about us? *

• Friend
• Family
• Car Signage
• Studio Signage
• Google
• Referral
• Other

I confirm that all the information I have provided is true and correct *

• Yes

By inserting my name below I confirm that I have read the T&Cs and Service Agreement (found below the submit button) and agree to terms of service *

Submit

View our T&C’s and Service Agreement Here