PERSONAL
First Name
Last Name
Age
Height
Date of Birth
Place of Birth
Home Address
Email Address
How often do you check your email?
Best Contact Number
Current Weight
Weight 6 Months Ago
Weight 1 Year Ago
Would you like your weight to be different? If so, how?
SOCIAL
Relationship Status
Any Children?
Any Pets?
Occupation
How many hours do you work per week?
Are you a part of any community/ volunteer groups?
GENERAL HEALTH
What are your main health concerns?
How is your current digestive health? e.g. discomfort, pain, bloating, constipation, diarrhea, gas
How is your current mental health?
Have you struggled with digestive and/ or mental health in the past? If so, how and when was it resolved?
Any allergies or sensitivities?
How stressed do you feel on a scale of 1-10 (1 being a low stress level and 10 being a high stress level)
What is your work-life balance like on a scale of 1-10? (1 being more life and 10 being more work)
What is your skin health like?
Any other health symptoms or concerns? e.g. pain, stiffness, swelling
Any current or previous serious illnesses, hospitalisations or injuries? If so, when and what happened?
At what point in your life did you feel your best? What were you doing?
How is/was your mother's health?
How is/was your father's health?
What is your ethnicity?
What is your blood type?
How is your sleep?
How many hours do you sleep per night?
Do you wake in the night? If so, how often?
WOMEN'S HEALTH
Have you reached or are you approaching menopause?
Are your periods regular?
How many days does your period last?
How many days is your cycle?
Are your periods painful or symptomatic?
What is your birth control history?
MEDICAL
List all supplements or medications you're currently taking:
Have you or are you currently seeing any other health professionals? e.g doctors, therapist
What physical movement/ exercise do you currently do on a weekly basis? and how long for?
FOOD
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook? What percentage of your food is home cooked?
Where does your non-home-cooked food come from?
What foods did you eat often as a child?
Breakfast
Lunch
Dinner
Snack
Liquids
What do you typically eat in a day? The more specific you are, the more I can help.
Breakfast
Lunch
Dinner
Snack
Liquids
Do you crave sugar, coffee, cigarettes or anything else?
Do you have any other minor/ major addictions?
What do you think is the most important thing you should change about your diet to improve your health?
HEALTH GOALS
What 3 BIG health goals do you want to achieve most for your health and wellbeing? e.g. enjoy exercising 5 times a week to feel great in your body!
ADDITIONAL COMMENTS
Is there anything else you would like to share?
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