Nutrition Programme Questionnaire

Name

Address

Contact Number *

Email *

Height

Weight

Resting Pulse

Occupation

Do you have children? (If so please include ages and genders)

Doctor's name and address

Are they aware you are seeing a nutritional therapist?

Yes
No

May we contact your GP?

Yes
No

What are you reasons for seeking nutritional advice?

Please include as many reasons as you can think of

Current life goals

Career, family, health

What (if any) illnesses are present on your mother’s / father's side of the family?

Medical History. Please list any illnesses or operations (excluding colds or flu, unless persistent) starting from your childhood, to the present day.

For each illness, please include the date, age at onset, and any medications taken.

Do you have any diagnosed conditions or diseases?

Please state who diagnosed each condition and when.

If you are currently undergoing any form of medical treatment please give details?

Include name, dose and regularity of consumption.

Which nutritional supplements, herbal or homeopathic remedies (regularly or occasionally) do you use?

If so, please list including doses and manufacturers name.

Which complimentary therapy practitioners have you visited? (e.g. osteopath, acupuncturist, herbalist etc.).

Please give information re: dates and treatment.

Do you follow or have you ever followed any dietary plan, regime or principles e.g. Atkins / high protein, vegetarian, food combining, GI principles, raw foods? If yes please list.

How often do you shop for fresh food?

Do you choose organic foods?

Do you enjoy preparing food?

Do you use a microwave?

What food or meal would you eat as a treat?

Are there any foods you would find hard to give up?

Are there any foods or drinks that you avoid or adversely effect you?

How willing are you to change the way you eat and experiment with new foods?

Reluctant
Willing to experiment
Enthusiastic about change

Feel free to be honest. There is no “right” answer.

How much time per day do you spend on your mobile phone ?

Do you drink tap water (including tea / coffee)?

What do you do in order to relax?

How many units of alcohol do you consume per week?

(1 pint beer = 2, 1 glass wine = 1.5)

Do you smoke?

Yes
No

What do you consider to be your greatest strength?

Nutrition Programme Questionnaire

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