Questionnaire

Completing this questionnaire is important to enable me to advise you further. Any information you give will be treated in the strictest confidence. Please email your responses and any other relevant information to ann@empowering-nutrition.com. Your inquiry will be responded to within 24 hours.

Health Questionnaire

Name

Fem/ Male

Date of Birth

Marital Status

No of Children & Ages

Job Description

Address

Line 1

Line 2

Post Code

Tel No:

email:

Personal Details

Weight in Kgs

Height in metres

Lowest adult weight

Heaviest adult weight

Desired weight

Why do you want to lose weight?

How much weight would you like to lose?

Have you visited a Doctor in the last year for any of the following: Please tick and briefly state extent of your condition.

Heart Condition

Type 2 Diabetes

High Blood Pressure

Cancer

Anxiety or Depression

Digestive Problems

Osteoporosis

Anaemia

Thyroid Problems

Please list below any surgical procedures undertaken.

Please list below any medication taken

Please list below any Nutritional Supplements taken.

Nutritional Information on your present diet

No restrictions

Vegetarian

Lacto Vegetarian

Lacto Ovo vegetarian

Salt restriction

Carbohydrate restriction

Calorie Restriction

Any other dietary plans

Indicate if any of the foods listed below should be excluded from your diet. Add any other.

 Dairy

Eggs

Soy

Corn

Wheat

Gluten

Red meat

 

 

 

 

 

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