Health Questionnaire

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Check the conditions that apply to you or to any members of your immediate relatives:

Have you been diagnosed with any specific illnesses, and if so, when? Please list and describe.

Have you received any previous treatment for these illnesses? Please explain.

Have you had any surgeries? If yes, please list and explain.

Have you had any pathology testing/scans in the last 12 months? Please list and explain.

Please bring these results with you to your first consultation, or alternatively, you can email them to lina@nourishmindbodynutrition.com.au prior to your consultation. Thank you.

Check the symptoms that you're currently experiencing:

What is your primary concern and reason for consulting a nutritionist?

What are your goals for this consultation and moving forward?

Are you currently taking any medication and/or supplements?

If yes, please specify the product and dosage.

Do you have any known allergies?

Do you have any known food intolerances?

If yes, please specify and explain how this was diagnosed.

Do you have any other comments or questions?

Thank you for taking the time to complete this questionnaire. I look forward to meeting with you soon and working with you on your journey to holistic health.