First Name

Last Name

Email Address

Phone

Age

Birthdate (dd/mm/yy)

Height (cm)

Current Weight (kg) - optional

Occupation

Describe your Exercise/Recreation routine

What do you want to achieve from your Nutrition Consultation?

I have had my labs drawn within the last 6 months? (if yes please bring a them to your consult) I have had my labs drawn within the last 6 months? (if yes please bring a them to your consult) Yes No

Please check any that apply to your past medical history Please check any that apply to your past medical history High Cholesterol Anemia Cancer Diabetes Asthma Hepatitis Thyroid Disease Depression/Anxiety Heart Disease Kidney Disease Chronic Yeast Infection High Blood Pressure Allergies Eczema IBS Crohn's or UC Eating Disorder None of the above

What Treatment(s) (if any) have you tried?

Do you have any health concerns beyond the goals listed above?

When did you first experience these symptoms?

How have you dealt with these in the past? How have you dealt with these in the past? Medical Doctors Alternative Doctors/Practitioners Self Care

What other health practitioners are you currently seeing?

List Names/Specialites below

List Medications/Pharmaceuticals you are currently taking

List all Nutritional Supplements, Vitamins, Minerals and Herbs You Are Currently Taking

Menstruation cycles - which applies to you? Menstruation cycles - which applies to you? Regular/normal Present/Irregular Not Menstruating Contraception Does not apply to me

The following questions relate to the aspects of wellness most closely associated with your nutrition goals. HYDRATION: What do you typically drink throughout the day? And what is your average liquid consumption [estimate]?

METABOLISM: Have you experienced any recent fluctuations in weight?

DIGESTION: Do you have any other digestive issues not yet mentioned [ex: bloat, cramping, constipation, loose stool etc]?

INFLAMMATION: Are you currently injured? Or are you experiencing any chronic inflammation? If so - where?

ENERGY: Does your energy fluctuate much throughout the day? If so- when is it usually at it's lowest?

SLEEP: How is your sleep, how do you feel when you wake up in the morning?

STRESS: On a scale from 1-10 how high is your stress right now and what are your main sources of stress?

Have you seen a Nutritionist before? Have you seen a Nutritionist before? Yes No

Do you currently, or have you previously smoked? Do you currently, or have you previously smoked? Yes No

Have you ever been on a special diet before? (e.g low carb, vegan, paleo, keto etc) - if so please specify

Do you have any known food allergies [anaphylactic response], sensitivities, or intolerances?

Do you have symptoms IMMEDIATELY after eating like bloating, gas, sneezing or hives? If so, please explain:

Are you aware of any DELAYED symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc...? If so, please explain:

What are your favourite foods?

Are there foods you avoid purely out of preference? If so, please explain:

Which of the following foods do you consume regularly? Which of the following foods do you consume regularly? Soda Refined Sugar Fast Foods Dairy (milk, cheese, yoghurt) Diet Soda Alcohol Gluten (wheat, rye, barley) Coffee None of the above

How many alcoholic drinks do you consume in a week?

What percentage of your meals are home-cooked? What percentage of your meals are home-cooked? 10 20 30 40 50 60 70 80 90 100

Do you like to cook? Do you like to cook? Yes No

When you don't cook, where do you like to eat out?

Is there anything else you would like me to know about your current diet, history, or relationship to food?

FACTORS FOR SUCCESS When given directions, I tend to... FACTORS FOR SUCCESS When given directions, I tend to... follow the directions (I love structure and checklists). follow only the directions that make logical sense to me. develop a more flexible way of fitting direction into my life, on my terms.

I... I... easily stick to goals set by someone else. have a difficult time following through with goals set by someone else

After I receive directions, I tend to... After I receive directions, I tend to... stick to them regardless of whether someone knows I’m following them. stick to them only if I know someone will be checking in on my progress.

Would you allow me to add you to my email list to receive educational and inspirational content, news and updates Would you allow me to add you to my email list to receive educational and inspirational content, news and updates Yes No

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