Nutritional background

Please fill out the confidential details below and submit. Many thanks.

Name

First Name

Last Name

Subject

Message

Date of Birth

YYYY

Weight

Height

Phone

(###)

###

####

Current Health Concerns

Any illnesses, operations, etc

Current medication or supplements

Any relevant family medical history

Do you feel generally happy each day?

Is your job stressful?

Are you active daily?

Do you smoke? How much?

Do you drink alcohol? How much?

How is your sleep quality? Do you wake frequently?

What do you do to relax?

Do you enjoy cooking?

Do you have abdominal pain after eating certain foods?

Do you suffer from heartburn?

Do you feel sleepy in the afternoon?

Are your bowel movements regular?

Do you suffer from constipation or diarrhoea?

What are your favourite and least favourite foods?

Are there any foods you could not give up?

Which foods upset your stomach?

Who in your house does the cooking?

Do you snack because you are hungry or bored?

Do you eat out a lot?

Are you looking to lose weight? If so how much?

Are you looking to change your eating habits generally?