This questionnaire will be combined with information gathered during the consultation and used to build an individual nutritional programme specifically tailored to your needs and lifestyle.  Please answer the questions as accurately as you can. All personal information provided is strictly confidential.

Please complete the form in one sitting only and then submit. If you are interrupted or inadvertently submitted your form before completion, you can open a new version and start where you left off. As long as the Client Booking Reference is completed correctly, we'll match them up! 

Please indicate any health problems within your immediate family.
(E.g. asthma, eczema, cancer, obesity, CVD, autoimmune, diabetes etc.)

Read the following questions and fill in the number that applies:
(How significant is the symptom?  How true is the statement?  0 means not at all, 3 means extremely true.)

KEY:
0 (or leave blank) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)