Name
*
First Name
Last Name
Email
*
Mobile
*
(###)
###
####
Date of Birth
MM
DD
YYYY
Place of Birth
Age
Height (cm)
Current Weight (kg)
Weight one year ago (kg)
Would you like your weight to be different?
Yes
No
If so, how?
Relationship status
Single
Married
Divorced
De Facto
Other
Do you have children? If so, what age?
Do you have pets?
Where do you live?
Do you work full-time/part time? If so, how many hours per week do you work?
What is your main health concern/issue?
Do you have any other health concerns or goals?
At what point in your life did you feel the best?
Do you have pets?
Any current or previous serious illnesses, hospitalisations, or injuries?
How is/was your parent’s health?
e.g. heart problems, diabetes etc.
What is your blood type?
A
B
AB
O
Unsure
How many hours per night on average do you sleep?
Less than 5 hours
6 hours
7 hours
8 hours
More than 9 hours
How do you rate the quality of your sleep?
Poor
Average
Good
Great
Do you have any pain, stiffness, or swelling?
Do you have any constipation, diarrhea, or gas?
Do you have any allergies or sensitivities?
Do you take any supplements or medications? Please list:
Are you involved with any healers, helpers, or therapies?
What role do sports and exercise play in your life?
E.g. play soccer with friends twice a week, go to the gym twice a week
How many hours per week do you exercise or move your body?
less than 1 hour per week
between 1 and 2 hours per week
between 2 and 3 hours per week
between 3 and 4 hours per week
More than 4 hours per week
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Unsure
Do you cook?
What percentage of home cooked food do you eat?
Where does your non-home-cooked food come from?
What foods do you typically eat for breakfast?
What foods do you typically eat for lunch?
What foods do you typically eat for dinner?
What foods do you typically eat for snacks?
What foods do you typically eat for drink?
Do you smoke?
Yes
No
Do you crave sugar, coffee, or cigarettes? Do you have any other major addictions?
What is the most important thing you should change about your diet to improve your health?
Is there anything else you would like to share?
Survey
My day to day energy levels are good
I feel focused during the day
My dietary choices are good
I have a good work/life balance
Is it easy to fall asleep and stay asleep throughout the night
I often get headaches, muscle, joint aches or pains
My mental, physical and emotional health is good
I feel stressed often
I am happy with all my relationships
I have a support network that motivate me to be my best
