New Client Form and Health Questionnaire

Name

Gender

Male

Female

D.O.B

Occupation

Address

Best contact number

How did you hear about The Nutrition Coach

What are your main health issues that are currently concerning you?

Have you had any major health issues in the past 12 months?

Have you had any major illness in the past 5 years (please elaborate)

Are you currently taking any medicines and / or nutritional supplements? (Please specify name of medicine/supplement, dosage per day, since when, and reason for taking)

What is your current weight in kilos

Please list any specific intolerances, allergies or other food sensitivities that you have, or have been told you have

Would you consider your current diet “healthy”?

Yes

Take your time to answer this question: How do you generally feel in your body, currently?

What’s you’re general outlook on life? eg. Optimistic and light-hearted? Negative and oppressive?

WOMEN – Menstruating

What age did you start menstruating?

If known, how long is your cycle?

On average, how many days is your bleed?

Do you often skip periods?

Or are you currently not menstruating at all?

If so how long since your last period?

Are you currently taking the birth control pill?

Yes

How long have you been on it?

For any reason apart from contraception?

Do you experience PMS or other uncomfortable symptoms linked to your cycle?

Yes

If so, describe

WOMEN – Perimenopausal / Menopausal

Are you noticing signs of menopausal transition?

Yes

Or gone through menopause already?

Yes

Since when?

Describe your symptoms

Are you on HRT?

Yes

Or any other kind of hormone therapy or hormonal treatment?

Yes

Childhood and family history

If known, describe your mother’s health when she was pregnant with you, your birth (natural or caesarean section), if and for how long you were breastfed, and your general health as an infant:

Were you generally healthy or unwell as a child? Any recurring illnesses or particular health challenges?

Describe your (usual) diet growing up, as a child:

Do you have biological siblings; are you the eldest / youngest / middle child?

What are your parents’ nationalities (if known)?

Your parents’ current health? If deceased, what was the cause?

Lifestyle

1. Describe your living situation: (live alone / with partner / with children – how many, what age?)

2. Describe your job / responsibilities: (position held and work load / hours / travel)

3. Describe where you usually do your grocery shopping: (supermarket / green grocer / organic food store /farmers’ market)

4. Do you spend much time in the kitchen? Do you enjoy cooking? or do you prefer to eat out and/or buy read-prepared meals or take-away?

5. What would be your “comfort foods” or common food cravings?

6. Describe your usual exercise routine (if any) or general physical activities:

7. If / when you drink alcohol, what do you mostly drink; how many and how frequently?

8. Describe your usual sleeping patterns; are you more of a night-owl? Do you work late? What time do you usually go to bed? How many hours per night? Do you sleep heavily? If you wake through the night, what time do you usually wake up? Do you rise early in the morning feeling refreshed, or sleep-in waking up groggy?

Your habits

What “bad” habits do you have that you see as being unhealthy?

If in the past you have followed specific “diets”, what types were they and for how long? (eg. Low-carb, Low-fat, Paleo, Vegetarian, Vegan, Atkins, Macrobiotic, Juice fasting etc.)

Basal Temperature and Pulse Self-Test:
Record your temperature and pulse at the specified times, over three consecutive days.
Take first temp and pulse for day on waking, before getting up or drinking or eating anything.
With a digital or mercury thermometer, take your temperature (under the tongue with mouth closed). Please record your temperature in Celsius thank you. When taking pulse, make sure you’re in a rested state: count pulse at your inner wrist or neck over a 15 second period then multiply by 4

Day 1: Date:

Temperature on waking:

Pulse/minute:

Temperature 20-45 mins after breakfast:

Pulse/minute:

Temperature sometime between 1 – 3pm:

Pulse/minute:

Day 2: Date:

Temperature on waking:

Pulse/minute:

Temperature 20-45 mins after breakfast:

Pulse/minute:

Temperature sometime between 1 – 3pm:

Pulse/minute:

Day 3: Date:

Temperature on waking:

Pulse/minute:

Temperature 20-45 mins after breakfast:

Pulse/minute:

Temperature sometime between 1 – 3pm:

Pulse/minute:

Your usual food intake: Give 2 examples of each meal that best represents your ‘usual’ eating

BREAKFAST Approximate time:

Example #1:

Example #2:

MORNING SNACK (if any) Approximate time:

Example #1:

Example #2:

LUNCH Approximate time:

Example #1:

Example #2:

DINNER Approximate time:

Example #1:

Example #2:

DESSERT Approximate time:

Example #1:

Example #2:

ADDITIONAL DRINKS your average number of daily glasses/cups of each of the following:

Water

Alcohol

Bottled juice

Tea

Soft drink

Fresh fruit juice

Coffee (w milk/sugar?)

Vegetable juice

Sports/energy drinks

Your tastes

Please list for me your 3 favorite meals / foods, regardless of their nutritional benefits (or lack of!):

Please list for me your 3 very least favourite meals / foods:

Your main aims: What do you really want to get out of this?!

Please summarise your main reasons for making your appointment with me, what it is that you want to achieve and the main learnings that you want to take from me as your Nutrition Coach.