Health Questionnaire – Private Clients Only!

Name *

First

Last

Email *

Date of birth *

Height and weight *

What is the main reason you want to improve your health? *

What is your ultimate lifestyle goal? And what do you see being the biggest challenge in achieving this? (I.e., time, cooking skills, meal planning, etc.)

Have you got any specific (current) concerns? Give me as much information as possible. *

Have you had any operations? Please can you give as much detail as you feel comfortable sharing. (When and what) *

Do you take any medication (prescribed and over the counter)? What and how often? Do you suffer from any side effects? *

Do you take any supplements – vitamins and/ or other? What, what dosage and how often? *

How would you rate your daily stress level? Any recent trauma / stressful situation that you think affects your current lifestyle I need to be aware of? *

Have you got any allergies or food intolerance? Please provide details. *

What causes the biggest discomfort in your current lifestyle? What helps you cope with this? (I.e. When I struggle to fall asleep, I take valerian tablets, or go for a walk etc.) *

Do you exercise? If yes, what and how often and for how long? (Indicate if weekly/daily) *

Tell me about a typical day in your life? What routines do you follow, if any? (If on shift work, what does that look like?) *

What are your favourite meals? (List minimum 5-6!) *

Any dish or food item you dislike or cannot tolerate? *

Do you consume alcohol? What, how often and how much? (Weekly / daily) *

What other beverages do you drink? How often and how much? Coffee, coke, tea, coke – anything that contains caffeine please list. How much water do you drink? *

How many hours do you sleep at night? Do you wake up at night? Do you suffer with insomnia? *

How often do you cook for yourself a week? Do you enjoy cooking? Is there anything you would like to learn specifically? *

Anything else you would like to share with me? *

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