General Information – Researchtheme

This questionnaire will help assess how Nutrition and Lifestyle Coaching can help you gain or maintain optimum health. Please answer all the questions adding any additional information at the back. You do not need to answer the questions in italics.

General Information

Please provide your general information for the consultation.

First Name

Last Name

Address

State

Country

Date of Consultation

Mobile Number

Email Address

Date of Birth

Marital Status

Occupation

Number of Children

Children Details

Height

Weight

Is your weight stable, increasing or decreasing?

BMI:

Hip:Waist Ratio:

Current blood pressure (if known)

Cholesterol level (if known)

Have you had any blood tests recently? Why?

Have you experienced any digestive disorder as a result of travelling abroad?

Permission to contact your medical doctor?

Is your medical doctor aware of your intention to see a Dietary Counsellor?

Doctors name and Clinic address.

Telephone number

Text Input

Are you pregnant, planning to become pregnant or experiencing fertility problems at this time?

Medication

Please list allmedication you are currently taking and the duration and/or regularity of consumption (remember to include the Pill, antacids, painkillers, antibiotics, inhalers):