Nutritional Assessment Questionnaire Form

Nutrition and Lifestyle Questionnaire 💪🍃

Hi there! Please take a couple of minutes to fill out this form. This helps me determine if we're the right fit to work together. Just provide as much detail as possible, and I'll review your responses and get back to you via email. OR call or email me to discuss Looking forward to connecting with you
0457916105

morganhealth1@gmail.com
Name:

First NameLast Name
Email
example@example.com
Sex:

MaleFemale
Age:
Occupation
Height (cm)
Weight (KG)
Consultation 📄🖋
What are the main reason or symptoms for this consultation?
list any issues which you would like to resolve
What are your own lifestyle or wellbeing goals? What are you wanting to get out of this service?
Do you follow any of these diets?

VeganVegetarianCarnivorousPescatarianPaleoKetogenicLow-fatLactose freeDairy freeLow oxalate dietFODMAPGluten freeIntermittent fasting - 16:8
Do you follow any other diets not on the list above?
List any foods avoided due to personal or religious reasons
Do you have any digestive issues?
if so describe the feeling, when it occurs and potential food culprits.
Food allergies

GarlicDiaryEggsWheatSoyPeanuts or other nutsShellfishSesameOther
Frequency of bowel movemtent
how many times per week do you go for #2?
Frequency of urination
how many times per day do you go for a #1?
Environmentally allergies

PollenMoldCatsHouse dust mitesDogsBee stingsOther
Lowest and highest body weight?
Lowest: >16years old
How many months or years were in between these 2 weights?
Was you over or under weight as a child / teenager?
Do you sleep soundly?

YesNo
Blood sugar related issues. Tick any which apply

I crave sweets, eat it for a temporary boost of energy, then I later crashI have a family history of diabetes, hypoglycemia or alcoholismI get irritable, anxious, tired and jittery, or I have headaches intermittently throughout the day, but feel better temporarily after mealsI feel shaky 2-3 hours after a mealI eat a low-fat diet but can not seem to lose weightIf i miss a meal, I feel cranky and irritable, weak, or tiredIf I eat a carbohydrate breakfast (muffin, bagel, cereal, pancakes etc..), I can't seem to control my eating for the rest of the dayOnce I start eating sweets or carbohydrates, I can't seem to stopIf I eat fish or meat and vegetables, I feel good, but seem to get sleepy after eating a meal full of pasta, bread, potatoes, and dessertI seem salt sensitive (I tend to retain water)I feel tired a few hours after eatingI am tired most of the timeI have high blood pressureI have type 2 diabetesI have a family history of diabetes
List all prior and current diseases effecting you
Current and Previous injuries
Previous surgeries, hospitalizations, diseases
enter any which still affects you
Tick which applies

I have soft, cracked or brittle nailsI have dry, itchy, scaling, or flaking skinI have dandruffI feel aching or stiffness in my jointsI am thirsty most of the timeI have fewer than two bowel movements a dayI have light-colored, hard, or foul smelling stoolsI have poor mood, difficulty paying attention, and/or memory lossI have a family history of high LDL and/or low cholesterol, and high trigyycerides
Tick any which applies

I have seasonal or environmental allergiesI feel poorly after eating (sluggishness, headaches, congestion, confusion, phlegm)I work in an environment with poor lighting, chemicals, and poor ventilationI get frequent colds or infectionsI have a history of chronic infections (skin infections, canker sores, cold sores)I have allergies or get sinusitisI have asthmaI have arthritisI have dermatitis (eczema, acne, rashes)I have an auto-immune condition (fibromyalgia, rheumatoid arthritis, lupus)I have colitis or inflammatory bowel diseaseI have irritable bowel syndrome (spastic colon)I exercise less than 30 minutes 3 times per week
Lifestyle 🏃
Do you smoke cigarettes or vape?

YesNooccasionally (weekends)
Do you drink alcohol?

NoYes - 1 or 2 a nightYes - 3-5 a nightYes - only on the weekend - 4 drinksYes - only on the weekend - 8+ drinks
Do you drink caffinated drinks? if so how much? (coffee, energy drinks, pre-workout)

No1 per day2 per day3+ per day
Do you use recreational drugs?

NoYes
How many times per week do you workout?
Activity level. casual activities like walking the dog, shopping, mowing the lawn do NOT count.

Sedentary -less than 30m exercise per/day.Lightly activity - Intentional exercise 30m perday, or high intensity for 15mins.Active - fast walking 1.45h per/day, or 50m jog, or full day restaurant work)Very active (4.5h walking per/day, or 2 jog, or full day construction work)Extremely active (2h vigorous exercise per/day e.g boxing, rock climbing)

Daily energy levels - Rate your energy levels throughout the day, 1= low. 10= high

	Morning	Midday	Afternoon
1 to 10

Food relationship 🍏
Taste preference

SweetSavoury
When stressed do you eat more or less?

MoreLess
When stressed do you drink alcohol?

NoYes
How often do you cook dinner?
Do you enjoy cooking?

YesNo
How often do you buy take-out or eat out per week?
including breakfast, lunch, dinner
How much do you spend on groceries per week
Estimate
What is a "bad" eating habit you'd like to overcome?
Do you think you eat healthy?

YesNo
How many times a week do you eat fish?
including canned and fresh/frozen
How many times a week do you nuts and seeds?
Women only 🚺
Do you take any contraception medication?
Do you have regular menstrual cycle?
Are you pregnant?

YesNo
If so, how many weeks pregnant?
https://www.morganhealth.com.au/
Should be Empty:

Nutrition and Lifestyle Questionnaire 💪🍃

Consultation 📄🖋

Lifestyle 🏃

Food relationship 🍏

Women only 🚺