Pre-consultation Form
Name
*
First
Last
Telephone
*
E-mail
*
D.O.B
*
Occupation
*
Height
*
Weight
*
Have you recently gained or lost weight?
*
About you
*
Lifestyle & why you are here today
Women - pregnant/lactating/children
How would you describe your energy levels?
*
Are there any specific areas you would like to discuss?
*
List your top 3 goals
Goals
Goal 1
*
Goal 2
*
Goal 3
*
Current Diagnosis/Treatment
Do you have any medical Issues?
*
High Blood Pressure/Diabetes/etc
Are you taking any medication?
*
Do you take any supplements?
*
Do you have any other medical information that may be useful? (medical history)
*
Dietary Habits
Do you have specific dietary requirments?
*
vegetarian, gluten free, religious/cultural food choices.
How many portions of fruit do you typically consume daily?
*
How many portions of vegetables do you typically consume daily?
*
How often do you eat red meat?
*
How much water do you drink daily?
*
How often do you eat fish?
*
Do you drink alcohol? If so, how much?
*
Do you smoke?
*
Do you have any food allergies?
*
Are there any foods that you dislike?
*
Please write down your typical day's food and drink consumption
Food Diary
Breakfast
*
Snack
*
Lunch
*
Snack
*
Dinner
*
Snack
*
What do you want to change most about your eating habits?
*
Exercise
Exercise
Number of Days per week
Duration and description of session
1. Exercise
*
1. Number of Days per week
*
1. Duration and description of session
*
2. Exercise
*
2. Number of Days per week
*
2. Duration and description of session
*
3. Exercise
*
3. Number of Days per week
*
3. Duration and description of session
*
4. Exercise
*
4. Number of Days per week
*
4. Duration and description of session
*
Sleep
How much sleep do get on average?
*
Rate your sleep quality from 1 to 10
*
Digestion
How often do your bowels move per day?
*
Do you suffer from constipation or diarrhea regularly?
*
Do you have any other digestive issues?
*
Miscellaneous
Is there any other information that you feel is important to note?
*
If you are signed up to FITT Meals, which plan are you on?
*
(low cal/lean/MG and how many meals do you recieve from us daily?)
Email
Submit
×
×
Cart