Online Nutritional Therapy for weight loss & wellbeing

Please select Nutritional therapy

Health & Wellbeing

Weight Management

IBS Nutritional Therapy

Type 2 Diabetes Nutritional Therapy

Perimenopause Nutritional Therapy

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High Blood Pressure Nutritional Therapy

First name

Surname

Country

Age

Marital status

Gender at birth

Male

Female

Intersex (hermaphrodite)

Email

Ethnic background

Weight

Height

Occupation

Which hours do you work?

Day Shift

Night Shift

Do you have any medical condition?

Yes

No

If yes please inform us of your medical condition

Do you consume any medication?

Yes

No

If yes please provide details of your medication

Do you have any allergies/food intolerance?

Yes

No

If yes please provide details

Do you consume any supplements?

Yes

No

If yes, please provide details

(If applicable) Which section of your body do you wish to reduce weight from?

Stomach

Hips

Whole Body

Do you have any bloating issues?

Yes

No

Which diet structure do you follow

Carnivore (meat consumer)

Vegetarian

Vegan

Pescatarian

If you follow the Carnivore diet (meat consumer), which meat do you consume the most?

Chicken

Lamb

Beef

Pork

How many times do you consume meat per week?

Which salt do you use in your cooking?

Table Salt

Himalayan Salt / Pink Salt

Sea salt

Not sure

How many meals do you have per day?

What do you usually have for breakfast?

What do you usually have for lunch?

What do you usually have for dinner?

Which foods do you experience cravings for most frequently?

Do you consume refined carbohydrates? (White bread, White flour)

Yes

No

If you consume refined carbohydrates, how many times per week

Do you consume ready made meals?

Yes

No

Food preference

Warm meals

Cold meals

Both

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?

Cigarettes

Alcohol

E Cigarettes / Vape

N/A

If so how much do you consume per day?

Do you have takeaways?

Yes

No

If yes, which type of takeaway do you consume?

If other, please provide details

How many times in a month do you have takeaway?

Do you exercise?

Yes

No

If yes, which type of exercise do you preform?

Gym

Walking

Running

How many times do you exercise per week?

Please list any further information below

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Online Nutritional Therapy questionnaire form (Please complete this form to the best of your ability)

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