health, diet, and lifestyle questionnaire
please complete prior to your initial consultation
Email - please use the same email address used when making the booking
*
example@example.com
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Day
-
Month
Year
Date
Gender
*
Female
Male
Prefer not to say
Weight
Height
Occupation
GP Details - if known please include the name and address of your GP
Do you give us consent to contact your GP if needed?
Yes
No
Have you seen a nutritionist or dietitian before?
Yes
No
What is your main purpose for seeing a nutritionist? (select any that apply)
Weight loss
Weight gain
To address a food intolerance
To address a health condition
Nutrition advice pre/during/post pregnancy
Sport nutrition
Improved general health/nutrition
Improved energy
Other
Please list the goals you wish to achieve by seeing a nutritionist (e.g. lose 5 kilos in 3 months; identify food triggers for my IBS)
Select any of the following health conditions that apply
Allergies
Anxiety/Depression
Arthritis
Asthma
Cancer
Coeliac disease
Gastrointestinal condition (e.g. gastroesophageal reflux disease; inflammatory bowel disease (Crohn's, ulcerative colitis); small intestinal bacterial overgrowth; irritable bowel syndrome; diverticulitis)
Diabetes type I
Diabetes type II
Disordered eating
Fatty liver disease
Food intolerance
Gall stones
Gout
Heart disease
High blood pressure (hypertension)
High cholesterol
Hormonal imbalance
Kidney disease
Menopause
Nutrient deficiency
Osteoporosis
Polycystic Ovary Syndrome
Pregnant
Rheumatoid arthritis
Skin condition (e.g. acne; dermatitis; eczema; hives; psoriasis; rosacea)
Stress
Thyroid condition (e.g. Hashimoto's thyroiditis; hyperthyroidism; hypothyroidism; Graves disease)
None of the above
Other
If you have ticked any of the health conditions above, please give details
Please list details of any medications you are currently taking (include frequency and dose)
Please list details of any dietary supplements (i.e. omega-3, multivitamin, etc.) you are currently taking (include frequency, dose, and brand)
Choose what best describes your current diet (select any that apply)
Dairy free
Flexitarian diet
Gluten free
Intermittent fasting
Ketogenic
Low FODMAP
Organic
Paleo diet
Sugar free
Vegan
Vegetarian
Other
Choose what best describes your current dietary habits (select any that apply)
Binge eater
Eating too quickly
Eating on the run
Emotional eater
Fussy eater
Mindless eating
Midnight snacking
Over-snacking
Over-eating
Poor appetite
Poor portion control
Sweet tooth
Under-eating
Other
Choose what best relates to your current lifestyle (select any that apply)
Athlete
Avid exerciser
Busy social life
Desk job
Easily fatigued
High stress
Poor sleeper
Regular traveller
Shift worker
Smoker
Other
Do you eat takeaways more than once a week?
*
Yes
No
Don't know
If you answered yes, please list source and frequency (e.g. Thai 2 x week, Subway 3x week)
Do you dine out in restaurants/cafes more than once a week?
*
Yes
No
Don't know
If you answered yes, please list typical outlets, frequency, and whether it is usually for brunch, lunch, or dinner
Do you subscribe to a meal service (e.g. HelloFresh, My Food Bag, etc.)
Yes - 4 or more times per week
Yes - 3 or less times per week
No
Sometimes
Other
How many alcoholic drinks do you have per week?
How many caffeinated drinks do you have per week? (including tea, coffee, energy drinks - please specify)
What is your living situation?
Live alone
Live with flatmates/family
Live with partner/spouse
What best describes your cooking habits?
Main cook of the house
Share cooking responsibilities
Rarely cook
Never cook
If you ticked "rarely cook" or "never cook", please give details why (e.g. too busy, don't know how, I'm just a kid)
How often do you engage in some form of exercise/ physical activity?
4 - 6 x week
2 - 3 x week
1 x week
Rarely
Never
Please provide details of exercise. Specifically, type of exercise, frequency, and duration (e.g. jogging, 3 x week, 20 minutes)
If you ticked "rarely" or "never", do you intend to start an exercise regime in the near future, or would you like advice on where to start?
How did you hear about belle époque nutrition?
Referral
Online search engine (e.g. Google)
Social media
Print media
Other
I consent to share this information with Mitchell Weston Nutrition LTD and that all of the information is correct at the date of completion of this form. All information provided will be held in strict confidence. I also agree to the terms and conditions and the late cancellation fee.
*
Yes
Submit
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