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