Online Nutritional Therapy for weight loss & wellbeing

Was this plan purchased by you?

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If no, please provide the name of the purchaser

First name

Surname

Age

Marital status

Gender at birth

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Transgender

Email

Ethnic background

Do you suffer from any other medical condition?

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No

If yes please inform us of your medical condition

Do you consume any medication?

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No

If yes please provide details of your medication

Do you suffer from any allergies/food intolerance?

Yes

No

If yes please provide details

Do you consume any supplements?

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No

If yes, please provide details

Which diet structure do you follow

Carnivore (meat consumer)

Vegetarian

Vegan

Pescatarian

Please can you inform us which meal you have for breakfast and the ingredients.

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Please can you inform us which meal you have for lunch and the ingredients.

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Please can you inform us which meal you have for dinner and the ingredients

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Which type of salt do you use for cooking?

Pink salt/Himalayan salt

Sea salt

Table salt

Which type of oil's do you use for cooking?

Vegetable oil

Olive oil

Rapeseed oil

Do you use butter/gi for cooking?

Yes

No

Do you have your meal after 8pm?

Yes

No

Do you have any particular food cravings?

Do you consume ready made meals?

Yes

No

Do you consume snacks / soft drinks?

Yes

No

If yes, how much snacks or soft drinks do you consume?

Do you consume any of the following?

If so how much do you consume per day?

Do you have takeaways?

Yes

No

If yes, which type of takeaway do you consume?

How many times in a month do you have takeaway?

Do you exercise?

Yes

No

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Plan Questionnaire

Healthy Eating Plan Questionnaire Form (Please complete this form to the best of your ability)

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