Pre-consultation Form
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Name
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First
Last
Mobile
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E-mail
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D.O.B
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Occupation
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Height
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Weight
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Have you recently gained or lost weight?
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About you
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Lifestyle & why you are here today
Women - pregnant/lactating/children
How would you describe your energy levels?
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Are there any specific areas you would like to discuss?
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List your top 3 goals
Goal 1
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Goal 2
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Goal 3
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Current Diagnosis/Treatment
Do you have any medical Issues?
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High Blood Pressure/Diabetes/etc
Are you taking any medication?
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Do you take any supplements?
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Do you have any other medical information that may be useful? (medical history)
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Dietary Habits
Do you have specific dietary requirments?
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vegetarian, gluten free, religious/cultural food choices.
How many portions of fruit do you typically consume daily?
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How many portions of vegetables do you typically consume daily?
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How often do you eat red meat?
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How much water do you drink daily?
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How often do you eat fish?
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Do you drink alcohol? If so, how much?
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Do you smoke?
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Do you have any food allergies?
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Are there any foods that you dislike?
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Please write down your typical day's food and drink consumption
Breakfast
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Example: Breakfast: 2 slices of toast with butter, coffee with milk and sugar
Snack
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Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana
Lunch
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Example: Lunch: large portion of rice with chicken and 2 vegetables
Snack
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Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana
Dinner
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Example: Dinner: small portion of pasta with pesto sauce with 1 chicken breast, no vegetables
Snack
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Example: Snacks: Large bowl of ice cream, 1 apple, 1 banana
What do you want to change most about your eating habits?
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Exercise
Exercise
Number of Days per week
Duration and description of session
1. Exercise
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1. Number of Days per week
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1. Duration and description of session
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2. Exercise
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2. Number of Days per week
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2. Duration and description of session
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3. Exercise
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3. Number of Days per week
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3. Duration and description of session
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4. Exercise
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4. Number of Days per week
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4. Duration and description of session
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Sleep
How much sleep do get on average?
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Rate your sleep quality from 1 to 10
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Digestion
How often do your bowels move per day?
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Do you suffer from constipation or diarrhea regularly?
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Do you have any other digestive issues?
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Miscellaneous
Is there any other information that you feel is important to note?
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If you are signed up to FITT Meals, which plan are you on?
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(Low Cal/Lean/Muscle Gain/Vegetarian and how many meals do you receive from us daily?)
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