Your nutritional reboot

The foods we choose to consume to nourish our bodies, Are so important to our overall health and vitality.

This holistic assessment will help you find real solutions that your body needs.

How to fill out this questionnaire:

Below is your overall health and lifestyle snapshot. Take your time and answer every question. If for some reason something important relating to you is not asked, feel free to use the sections at the end to add any further comments!

It will take you approx. 5 mins to complete.

Why are there questions about my bodily functions??

How we feel, our general health condition and complaints, can be directly affected and influenced by our nutritional status. Remember HEALTH is HOLISTIC. It is important to ask (sometimes uncomfortable) questions, especially in relation to your digestive health, to assess how your body is processing, and assimilating different foods and nutrients. Your body can tell us if there are any signs of excesses or deficiencies, and how that is affecting your health overall. It is also essential for me to know any medications including supplements, to avoid any interactions.

The more information you can provide, the more I can uncover for you.

Let’s get going……

Name

First Name

Last Name

Date Of Birth:

YYYY

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Current weight (kg):

Current Height (cm):

Please list any medications or supplements taken:

Please list any CURRENT health conditions I need to know about:

If none, please wite "NONE".

What are your current health goals? What you you like to work on?

Do you suffer from any intolerances or allergies?

Describe what you would commonly have for breakfast. Please list all options.

What time would you typically have breakfast?

Describe what you would commonly eat for lunch. Please list all options.

What time is lunch usually for you?

Describe what you would commonly eat for dinner. Please list all options.

What time do you usually eat dinner?

How much alcohol do you consume?

How much dairy do you consume?

I consume fruit:

Select which best describes your fruit intake:

I consume vegetables:

Select which best describes your veggie intake:

List the types of vegetables you like to eat:

How often do you eat fish/seafood?

How often do you eat red meat?

How often do you eat chicken?

How often do you eat eggs?

How often do you eat sweet foods?

This includes biscuits, cakes, confectionary, chocolate, lollies etc.

Do you eat bread?

This includes white, wholegrain, seeded, sourdough, gluten-free etc.

Describe what type of breads you like to eat:

How often do you consume takeaway foods?

What types of takeaways do you usually consume?

How much water do you drink?

Which best describes your coffee intake:

How often do you drink black teas?

This includes teas such as English breakfast, ceelong, earl grey, rooibos.

Which areas of your diet would you like to improve?

Do you follow a specific diet? If so, why?

What blocks stop you from eating well?

Are there any foods that you find give you digestive issues/upsets?

Are there any foods you dislike due to taste?

What time is your last meal/snack of the day? What do you usually have?

Do you feel stressed when eating? Rushing? Fast eater?

Are meal times usually enjoyable?

Do you enjoy cooking? Or it's just not your thing?

Do you commonly skip meals? If YES, how often do you do this? Which meals/meals are commonly skipped? Why?

Do you suffer from any of the following:

Click all that apply.

Bloating

IBS

Abdominal cramps

Diarrhoea

Constipation

Flatulence

Nausea

Reflux/heartburn

Burping

Levels of stress currently:

On a scale of 1-10. 1 = no stress, 10 = extreme stress.