Nutritionist Consultation

1
I confirm that I am 18 years of age or older, using this service voluntarily and on my own behalf. Any treatment or advice provided is intended solely for my personal use.
Agree
Disagree
2
partner
3
Burkes Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
Havens Pharmacy Macroom
Carrigtwohill Pharmacy
I prefer sending to another pharmacy
4
McGorisks Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
McGorisks Pharmacy, The Crescent
McGorisks Pharmacy, Clonbrusk
McGorisk's Pharmacy, Ballinasloe
McGorisks Pharmacy, Athlone
5
Molloy Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
Molloys Pharmacy - Garden Street, Ballina, F26 W951
Molloys Pharmacy - Bunree Road, Ballina, F26 Y9PF
Molloys Pharmacy - Main Street, Crossmolina, F26A4E3
Molloys Pharmacy - The Harrison Centre, Roscommon, F42 H002
Molloys Pharmacy - Ballaghaderreen, Co. Roscommon, F45X896
Molloys Pharmacy - Knocknacarra, Co. Galway, H91VPX2
Molloys Pharmacy - Davitt Quarter, Achill Island, F28V4P0
Molloys Pharmacy - Claremorris, F12RX02
I prefer sending to another pharmacy
6
Scanlon Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
Please Select
Please Select
SCANLONS PHARMACY, ENNIS RD BRANCH
SCANLONS EXPRESS LATE NIGHT PHARMACY, DOCK ROAD
SCANLONS PHARMACY, CASTLETROY BRANCH
LIMITLESS HEALTH PHARMACY
7
Full Pharmacy Name and Address is Required* This field is required.If Successful Your Script will be sent to this pharmacy.
If you do not provide correct details your application may be denied.
8
Name* This field is required.
First Name
Last Name
9
Email* This field is required.
example@example.com
Confirm Email
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Date of Birth* This field is required.
Date
Day
Month
Year
12
Phone Number* This field is required.
Area Code
Phone Number
13
Please specify your gender* This field is required.
MALE
FEMALE
14
Height* This field is required.
15
Current Weight* This field is required.
16
What is motivating you to seek nutrition counselling? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
What do you want to focus on during your consultation? What are your goals? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
What are your main challenges to living a healthier lifestyle?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Please describe any medical diagnoses that impact your food or physical activity choices.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Digestive History: Please list any ongoing symptoms, food allergies or intolerances.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
21
Family History: Please list all major immediate family diagnoses.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
22
Supplements/Medications: Please list any supplements or medications you take * This field is required.
Huge
Large
Normal
Small
Ok
Ok
23
Weight history: Please describe any weight fluctuations you have experienced in the past * This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
Describe a typical work day* This field is required.Include Work Schedule, commute time etc
Huge
Large
Normal
Small
Ok
Ok
25
Describe a typical day off * This field is required.
Huge
Large
Normal
Small
Ok
Ok
26
On average, how many hours do you sleep on weeknights?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
What types of physical activities do you enjoy? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
28
How often do you participate in these activities? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
29
Who prepares meals in your home and for how many?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
30
Who does the shopping and where? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
31
How many meals per week are home-prepared?* This field is required.
Quantity
Breakfast
Row 0, Column 0
Lunch
Row 1, Column 0
Dinner
Row 2, Column 0
Breakfast
Lunch
Dinner
Quantity
Row 0, Column 0
Quantity
Row 1, Column 0
Quantity
Row 2, Column 0
1 of 3
32
How many meals per week do you eat out or buy and bring in to eat?* This field is required.
Quantity
Breakfast
Row 0, Column 0
Lunch
Row 1, Column 0
Dinner
Row 2, Column 0
Breakfast
Lunch
Dinner
Quantity
Row 0, Column 0
Quantity
Row 1, Column 0
Quantity
Row 2, Column 0
1 of 3
33
How many days per week do you skip meals?* This field is required.
Quantity
Breakfast
Row 0, Column 0
Lunch
Row 1, Column 0
Dinner
Row 2, Column 0
Breakfast
Lunch
Dinner
Quantity
Row 0, Column 0
Quantity
Row 1, Column 0
Quantity
Row 2, Column 0
1 of 3
34
List the Restaurants you frequent most often* This field is required.
Huge
Large
Normal
Small
Ok
Ok
35
Please list any special diets that you have tried in the past or are currently on* This field is required.
Huge
Large
Normal
Small
Ok
Ok
36
Please note number of servings of each beverage you drink in a typical week. * This field is required.
Quantity
Tea/Coffee
Row 0, Column 0
Alcohol
Row 1, Column 0
Soda/Energy Drinks
Row 2, Column 0
Juice
Row 3, Column 0
Water
Row 4, Column 0
Tea/Coffee
Alcohol
Soda/Energy Drinks
Juice
Water
Quantity
Row 0, Column 0
Quantity
Row 1, Column 0
Quantity
Row 2, Column 0
Quantity
Row 3, Column 0
Quantity
Row 4, Column 0
1 of 5
37
Food Record Fruits, vegetables, cooked grains, beverages: 1/2 cup = 1/2 a tennis ball •Meat, chicken, fish: 3 oz (90g) = Deck of cards •Peanut butter, salad dressing, cream cheese, mayonnaise, oil: 1 Tablespoon = 1/2 a ping pong ball
Time (example 7.30am)
Food/Beverage (Oatmeal, Black Coffee )
Amount ( 1 packet, 12oz)
Notes "Breakfast at my desk"
Breakfast
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Mid Morning
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Lunch
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Mid Afternoon
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Dinner
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Bedtime
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Breakfast
Mid Morning
Lunch
Mid Afternoon
Dinner
Bedtime
Time (example 7.30am)
Row 0, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 0, Column 1
Amount ( 1 packet, 12oz)
Row 0, Column 2
Notes "Breakfast at my desk"
Row 0, Column 3
Time (example 7.30am)
Row 1, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 1, Column 1
Amount ( 1 packet, 12oz)
Row 1, Column 2
Notes "Breakfast at my desk"
Row 1, Column 3
Time (example 7.30am)
Row 2, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 2, Column 1
Amount ( 1 packet, 12oz)
Row 2, Column 2
Notes "Breakfast at my desk"
Row 2, Column 3
Time (example 7.30am)
Row 3, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 3, Column 1
Amount ( 1 packet, 12oz)
Row 3, Column 2
Notes "Breakfast at my desk"
Row 3, Column 3
Time (example 7.30am)
Row 4, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 4, Column 1
Amount ( 1 packet, 12oz)
Row 4, Column 2
Notes "Breakfast at my desk"
Row 4, Column 3
Time (example 7.30am)
Row 5, Column 0
Food/Beverage (Oatmeal, Black Coffee )
Row 5, Column 1
Amount ( 1 packet, 12oz)
Row 5, Column 2
Notes "Breakfast at my desk"
Row 5, Column 3
1 of 6
38
GDPR Consent Form* This field is required.To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment. Declaration  I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.  I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.  I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.  I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.  I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.  I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.  I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.  I understand that I can withdraw consent for processing of my personal health data at any time.
I confirm my consent.
39
My Products* This field is required.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costEUR
Eligibility ConsultationOnline Consultation Fee
€120.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Enter Coupon
Total cost €0.00
First Name
Last Name
Should be Empty: