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

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?)