Nutrition Programme Questionnaire

This questionnaire is designed to provide all the information necessary to build you an individual nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.

This questionnaire is quite extensive (8 pages), please make sure that you have all of the details ready prior to filling in, to preview the details that you will require please have a quick look at the pdf version.

All details on this questionnaire will be regarded as private and confidential.

Personal details

First Name:		Last Name:		Title:	Mr Mrs Miss Ms Dr
Date of Birth:		Age:
Address:
Postcode:		Email address :
Tel (work):		Tel (home):		Tel (mobile):
Occupation:		Height:		Weight:
Medical Doctor’s address:
Doctor’s Postcode:		Doctor’s Tel. No:
1) Do you give permission for your medical doctor to be contacted?					Yes No
2) Is your medical doctor aware of your intention to see a nutrition consultant?					Yes No
3) Have you seen a nutrition consultant, or any other health professional before, regarding your symptoms?					Yes No
4) Have you had any blood, urine, saliva or any other laboratory tests?					Yes No
If YES please state which tests, and if possible bring a copy of the results to your consultation.

Comments:

Please check your answers carefully before proceeding to page 2.