Consultation Form Name* First Last Date Of Birth* Date Format: DD slash MM slash YYYY AddressPhone - HomePhone - WorkEmail* Phone - MobileLiving Arrangements*AloneFlattingPartnerHusbandWifeChildren*NoYesHow many children?Females OnlyDo you suffer from PMS, cramping, heavy periods, mood swings, pelvic pain, etc? Please write what you suffer from.Do you suffer from PCOS or endometriosis?What are your nutrition goals and what would you like to know more about?* Weight/Fat Loss Manage emotional eating Muscle gain/increase size Help with food shopping Balanced lifestyle Sports nutrition Label Reading/Healthy Shopping Getting all your vitamins/minerals Increased energy Eating well when you travel Meal Ideas/Recipes Alcohol/Hydration What would you like to achieve by working with a nutritionist? *Medical HistoryAny current health problems (please tick) Fatty liver disease Shingles Endometriosis Chron’s Disease Inflammatory bowl disease Type 2 Diabetes Coeliac Disease Irritable bowl syndrome High Cholesterol High blood pressure Heart Disease Gout Osteoporosis Auto Immune Disease Heartburn/ reflux Lactose Intolerant Hypo/ Hyper Thyroid Depression Anxiety Hormonal Balance Low stomach acid Bad Acne/ Skin Other Are you on or currently taking any medication or supplements:Are you allergic to any medication?Smoker*NoYesIf previously, when did you stop smoking?Describe your digestive healthDo you suffer from Indigestion Bloating Reflux How often do you have a bowel motion?Do you have a tendency for constipation or diarrhoea?*NoYesEmotional HealthSleep =Energy Levels =Stress =Able to relax =Low Mood/Depression =Exercise/TrainingPlease explain your current exercise regime in as much detail as possible:Any exercise or sports goalsDo you have a coach or personal trainer?NoYesIf no, would you be interestedNoYesCurrent Food ManagementPlease explain your current eating regime in as much detail as possible*BreakfastLunchSnacksDinnerHow often do you food shop and where do you goHow many times do you eat during a day23456+Who does the cookingHave you ever been on a diet?Food HabitsDo you make or buy your own lunch?How much water do you drink a day?How many alcoholic drinks do you consume per week?How many times do you drink caffeinated beverages?What are your favourite foods?Are there any foods you avoid? NOTE: The service Key Nutrition provides is particular to your personal needs and circumstances. Key Nutrition’s advice to you is based on the information you provide to me during your consultation. It is important that you provide accurate information and notify me if your circumstances change. This will ensure that my advice to you is always accurate and in your best interests.