Health and nutritional questionnaire

Please complete the online form below to receive a quotation for an Eating Plan via e-mail:
All information submitted is kept CONFIDENTIAL
Name and surname
Tel / Cell
Email
Preferred  Language   Afrikaans  English
   
Sex
Age years
Weight (kg) kg
Height (cm) cm
Waist (cm) cm
Hips (cm) cm
Do you smoke?
Do you Exercise?
Type of exercise?
How much alcohol do you consume?
Please list any cronic illnesses, if any
Which of the following blood values are elevated?
Do you suffer from any of the following? Stomach cramps
Constipation
Diarrhoea
Reflux
Heartburn
Excess Gas
Food Intolerance
Food Allergies
Any other?
Have you been on any slimming Diets?
Is your weight fluctuating?
List current medication
List current supplements
Do you cook with Butter
Oil
Margarine
What do you usually have for breakfast?
What do you usually have for Lunch?
What do you usually have for Dinner?
What do you snack on?
 
Morning
Afternoon
Late Night
Do you binge eat?
How often?
How much of the following do you consume?
  Per Day Per Week
Milk
Fat Free
Full Cream
2% Fat
Yoghurt
Fat Free
Low Fat
Fruit
Fresh
Dehydrated
Canned
Juice
Vegetables
Cooked
Raw
Bread
White
Brown
Seed or Whole Grain
   
Other Comments
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