Pre-Client Consultation Form - Clinical Nutrition PRE-CLIENT CONSULTATION FORM - NUTRITION BIOGRAPHICAL DATA Name * Address * Postcode Phone Email * Date of Birth Age Gender Relationship Status Children Occupation General Practitioner Emergency Contact Section Buttons Next PRESENTING COMPLAINT Reason Consultation is Required Section Buttons Next MEDICAL HISTORY / LIFESTYLE DO YOU HAVE GOOD GENERAL HEALTH? IF NOT EXPLAIN PRIOR ILLNESSES ANY SURGERY/ HOSPITALISATIONS: IF SO EXPLAIN DO YOU TAKE PRESCRIPTION MEDICATION: IF YES PLEASE DETAIL DO YOU TAKE SUPPLEMENTS? IF YES PLEASE DETAIL HAVE YOU HAD ANY VACCINATIONS? DO YOU SMOKE OR HAVE YOU IN THE PAST? DO YOU TAKE RECREATIONAL DRUGS? DO YOU DRINK ALCOHOL? IF SO QTY PER WEEK DESCRIBE SLEEP PATTERN DO YOU EXERCISE? IF SO WHAT AND HOW OFTEN? DESCRIBE ENERGY LEVELS DESCRIBE STRESS LEVELS DO YOU OR HAVE SUFFERED FROM DEPRESSION OR ANXIETY? WHAT DO YOU DO FOR RELAXATION? Section Buttons Next FAMILY HEALTH HISTORY Mother Father Siblings Section Buttons Next DIETARY PARTICULAR FOOD DISLIKES DO YOU HAVE ANY ALLERGIES? DO YOU EXPERIENCE FOOD CRAVINGS? ANY KNOWN FOOD ALLERGIES INTOLERANCES? DO YOUR BOWELS ELIMINATE EVERYDAY? DO YOU DRINK COFFEE? IF SO HOW MANY PER DAY? HOW MUCH WATER DO YOU DRINK PER DAY? Section Buttons reCAPTCHA If you are human, leave this field blank. Submit Form to Debbie Buddle
