Dietetics Pre-Appointment Questionnaire
Please complete the form prior to your scheduled appointment with the Dietitian
Client's Name
*
First Name
Last Name
What brings you in?
What are your main reasons for seeking support from a dietitian?
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What are your goals or what would you like help with?
*
Your current eating habits
Please describe a typical day of eating (including meals, snacks, drinks):
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How many meals do you usually eat per day?
*
1-2
3
4+
Do you usually snack?
*
Yes
No
Do you ever skip meals?
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Yes
No
If yes, which meals and why?
How often do you eat takeaway or dine out?
*
Rarely
1-2 times a week
3+ times a week
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Food preferences & lifestyle
Foods you enjoy:
*
Foods you dislike or avoid:
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Do you follow any specific diet or eating pattern? (e.g. vegetarian, vegan, low-carb, halal, gluten-free)
*
Who usually prepares your meals?
*
Self
Partner
Family
Mix
How confident do you feel with cooking?
*
Not confident
Somewhat
Very confident
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Your relationship with food
How would you describe your relationship with food?
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Do you ever:
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Eat when stressed, bored, or emotional
Feel out of control around food
Feel guilt after eating
None of the above
Have you tried diets in the past?
*
Yes
No
If yes, what worked or didn’t work?
*
Health & medical information
Do you have any medical conditions or diagnoses?
*
Are you currently taking any medications or supplements?
*
Have you had any recent weight changes?
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Do you experience any of the following?
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Bloating
Reflux/heartburn
Constipation
Diarrhoea
Food intolerances/allergies
Other:
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Lifestyle factors
What does a typical day look like for you? (work, routine)
*
How would you describe your physical activity?
*
Low
Moderate
High
How is your sleep?
*
Poor
Okay
Good
How would you rate your stress levels?
*
Low
Moderate
High
Challenges & support
What do you find most challenging about eating well?
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What tends to get in the way?
*
What support would be most helpful for you?
*
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Goal setting
What are your top 1–3 goals?
Goal 1:
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Goal 2:
*
Goal 3:
*
On a scale of 1–10, how ready do you feel to make changes? 1 (not ready) – 10 (very ready): ___
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Strengths
What is currently going well with your eating or routine?
*
What has helped you make changes in the past?
*
Anything else
Is there anything else you would like your dietitian to know before your appointment?
*
Should be Empty: