Pre-consultation Form

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Name
Lifestyle & why you are here today
Women - pregnant/lactating/children

List your top 3 goals

Current Diagnosis/Treatment

High Blood Pressure/Diabetes/etc

Dietary Habits

vegetarian, gluten free, religious/cultural food choices.

Please write down your typical day's food and drink consumption

Example: Breakfast: 2 slices of toast with butter, coffee with milk and sugar
Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana
Example: Lunch: large portion of rice with chicken and 2 vegetables
Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana
Example: Dinner: small portion of pasta with pesto sauce with 1 chicken breast, no vegetables
Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana

Exercise

Exercise

Number of Days per week

Duration and description of session

Sleep

Digestion

Miscellaneous

(Low Cal/Lean/Muscle Gain/Vegetarian and how many meals do you receive from us daily?)
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