Nutrition Assessment Questionnaire

The questionnaire below includes a 3 day 'Food and Drink Diary', You can complete the diary online using the form below, or click here to download a Word version of the diary, complete it at your convenience, then upload it using the option in the 'Food and Drink Diary' section in the form below.

Please complete the questionnaire and the three day food and drink diary accurately and as fully as possible. The more information you provide, the easier it will be for me to give you the best possible advice.

 

Personal Details

Please note that fields marked * are required.

Title (Mr/Mrs/Miss/Ms etc)
Forename*
Surname *
Age
Date of Birth *
Gender *
Male Female
Address line 1 *
Address line 2
Town or City *
County or State
Country
Postcode *
E-mail address *
Telephone number
Occupation
Do you give permission for me to contact your GP regarding nutritional and other lifestyle recommendations made? *
Yes No
GP name
GP address

Health Profile

Body Weight: (if known)
(Stone/lb or kg)
Height: (if known)
(Feet or Metres/cm)

What is the main reason
why you are seeking
nutritional advice? *

Do you have any of the following health problems?
(Please tick all that apply)

Arthritis
Asthma
Cancer
Coeliacs Disease
Constipation
Diabetes (type I)
Diabetes (type II)
Heart Disease
High blood cholesterol
High blood pressure (Hypertension)
Osteoporosis
Overweight
Stroke
Other (Please specify below)
Are you currently taking any medication? *
Yes No
If yes, what medication are you taking and what dose? (If known)
Are you pregnant?
Yes No
Are you currently breast-feeding?
Yes No

Food Allergies and Intolerance

Do you have a food allergy or intolerance? *

Yes No
If yes, do you have a food allergy or intolerance to any of the following foods/ingredients?
(Please tick all that apply)

Celery
Cereals containing gluten, wheat, barley, rye and oats
Crustaceans (including crab, lobster and prawns)
Eggs
Fish
Lupin
Milk
Mollusc (including cockles, mussels, snails, squid, whelks)
Mustard
Nuts (almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pistachios, Queensland nuts, walnuts)
Peanuts
Sesame Seeds
Soya
Sulphur dioxide/Sulphites
Other (Please specify below)
If you have ticked yes to any of the above foods or ingredients, have you been tested and has a diagnosis been confirmed?
Yes No

Food Preferences

Are you a vegetarian? * Yes No
If yes, do you eat fish? Yes No  
Are you a vegan? * Yes No
Are there any foods you avoid for religious or cultural reasons?

Nutritional Supplements

Are you currently taking any nutritional supplements? *
Yes No
If yes, what is the name of the supplement and the dose? (If known)

Physical Activity

How often do you engage in moderate to vigorous intensity exercise each week? *
(Brisk walking, gardening or any similar activity that gets you slightly out of breath counts as moderate intensity exercise)

Never
Rarely
1-2 times per week
3-4 times per week
5 or more times per week

If you do exercise at a moderate to vigorous intensity, how long is the average duration of your exercise?

Three Day Food and Drink Diary

Please record all food and drink consumed over three days including snacks and food and drink consumed outside the home. Please base the food diary on three typical days and provide as much information as possible, including the time, types of food and drink e.g. wholemeal bread, semi-skimmed milk etc, cooking methods e.g. fried, grilled, boiled etc, brand names, estimation of portion size e.g. number of slices, size of a fist, glass, pint, teaspoon, table spoon etc where possible. The more information you provide, the easier it will be for me to give you the best possible advice.

You can complete your 'Food and Drink Diary' in the form sections below, or you can upload your completed 'Food and Drink Diary' Word document (available from the top of this page).

Upload a completed 'Food and Drink Diary' Word document.

Day 1

Day 2

Day 3

 

Terms and Conditions:

Please tick the box below to confirm that you agree to the following terms and conditions.

I confirm that all the information I have provided on the nutrition assessment questionnaire is accurate and complete to the best of my knowledge.

I agree that Healthy Eating for Life are not responsible for any illness or allergic reaction following eating or drinking any food or drink recommended to me as a result of any failure to disclose appropriate information on the nutrition assessment questionnaire.

I consent to Healthy Eating for life using the information I provide for the sole purpose of providing a nutritional and lifestyle advice service and that all information given is completely confidential and will not be disclosed to any third party without my consent.


I agree to the Terms and Conditions above

How you would prefer to receive the Nutritional Report?

A printed copy by Post
An electronic copy by E-mail

 

I am a qualified Public Health Nutritionist and the advice I offer is based on sound scientific evidence.

I offer no quick fixes or fad diets, but instead can show you the dietary changes that need to be made to improve health in the long term.

My approach is to encourage you to gradually make permanent dietary changes that are both realistic and will benefit your health in the long term.

The advice I offer is much broader than a typical weight loss class and covers a variety of health issues that can be affected by your nutritional status.

I can offer long term nutritional support and advice and can write follow-up reports in exactly the same way, but tailored depending on any changes to your diet and health status.

Please contact me for further information.

 

To prevent Spam, please enter the text you see in the image below into the box on the right.

  

Please click the 'Preview' button below if you'd like to preview your information before sending it.

Please click the 'Submit' button to send your information to us.

 

  

 

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