health, diet, and lifestyle questionnaire

health, diet, and lifestyle questionnaire

please complete at least 24 hours before your initial consultation
Email - please use the same email address used when making the booking*
example@example.com
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
Date
Gender*

FemaleMalePrefer not to say
Weight
Height
Occupation
GP Details - if known please include the name and clinic of your GP
Do you give us consent to contact your GP if needed?

YesNo
Have you seen a nutritionist or dietitian before?

YesNo
What is your main purpose for seeing a nutritionist? (select any that apply)

Weight lossWeight or muscle gainGut healthSport/exercise nutritionNutrition advice pre/during/post pregnancyNutrition advice peri-menopause/menopauseTo address a health conditionImproved general health/nutritionImproved energyOther
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; reduce cholesterol; etc)
Goal 1*
Goal 2
Goal 3
Select any of the following health conditions that apply

AllergiesAnxietyDepressionArthritisAsthmaCancerCoeliac diseaseGastrointestinal condition (e.g. gastroesophageal reflux disease; inflammatory bowel disease (Crohn's, ulcerative colitis); small intestinal bacterial overgrowth; irritable bowel syndrome; diverticulitis)Diabetes type IDiabetes type IIDisordered eatingFatty liver diseaseFood intoleranceGall stonesGoutHeart diseaseHigh blood pressure (hypertension)High cholesterolHormonal imbalanceKidney diseaseMenopauseNutrient deficiencyOsteoporosisPolycystic Ovary SyndromePregnantRheumatoid arthritisSkin condition (e.g. acne; dermatitis; eczema; hives; psoriasis; rosacea)StressThyroid condition (e.g. Hashimoto's thyroiditis; hyperthyroidism; hypothyroidism; Graves disease)None of the aboveOther
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)
Do you have a bowel motion every day?

YesNo
If no, how often?
Choose what best describes your current diet (select any that apply)

Dairy freeFlexitarian dietGluten freeIntermittent fastingKetogenicLow FODMAPOrganicPaleoSugar freeVeganVegetarianOther
Choose what best describes your current dietary habits (select any that apply)

Binge eaterEating too quicklyEating on the runEmotional eaterFussy eaterMindless eatingMidnight snackingOver-snackingOver-eatingPoor appetitePoor portion controlSweet toothUnder-eatingOther
Do you eat takeaways more than once a week?*

YesNoDon'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?*

YesNoDon'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 weekYes - 3 or less times per weekNoOccasionallyOther
How much water do you consume per day?
How many caffeinated drinks do you consume per week? (including tea, coffee, energy drinks - please specify)
How many alcoholic drinks do you consume per week?

None0 - 34 - 78 or more
What best describes your cooking habits?

Main cook of the houseShare cooking responsibilitiesRarely cookNever cook
If you ticked "rarely cook" or "never cook", please give details why (e.g. too busy, don't know how, not interested)
Choose what best relates to your current lifestyle (select any that apply)

AthleteAvid exerciserBusy social lifeDesk jobEasily fatiguedHigh stressPoor sleeperRegular travellerShift workerSmokerOther
Do you currently sleep 7- 9 hours per night?

YesNoStruggle to fall asleepWake frequently
What is your living situation?

Live aloneLive with flatmates/familyLive with one partner/spouse
How often do you engage in some form of exercise/ physical activity?

4 - 6 x week2 - 3 x week1 x weekRarelyNever
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?

ReferralOnline search engine (e.g. Google)Social mediaPrint mediaHealth professionalOther
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
Should be Empty:

health, diet, and lifestyle questionnaire

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; reduce cholesterol; etc)