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
Male
Female
Age
years
Weight (kg)
kg
Height (cm)
cm
Waist (cm)
cm
Hips (cm)
cm
Do you smoke?
-- please select --
No, I don't smoke
less than 5 per day
5 - 10 per day
10 - 20 per day
20 - 30 per day
more than 30 per day
Do you Exercise?
-- please select --
No, I don't exercise
1 time per week
2 times per week
3 times per week
4 times per week
5 times per week
6 times per week
7 times per week
Type of exercise?
-- please select --
Weights
Cardio
Walk the dog
How much alcohol do you consume?
-- please select --
None
Little
Moderate
High
Excessive
Please list any cronic illnesses, if any
Which of the following blood values are elevated?
None
Total Cholesterol
LDL Cholesterol
Triglycerides
Fasting Glucose
Insulin
Uric Acid
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?
Yes
No
Is your weight fluctuating?
Yes
No
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?
Yes
No
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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