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Thank You For Requesting Customised Nutrition Coaching

Please fill out the consultation form below

Please Take Your Time When Filling Out

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Please include as much information as you can. More data means your customised plan is more likely to work faster.

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Your responses provide necessary screening and duty of care requirements for insurance and legal purposes.

Custom Nutrition Plan Consultation Form

First Name*
Last Name*
Phone*
Email Address*
GENDER
Male
Female
date of birth
current weight
current height
what are your goals and target areas?
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what do you typically have for breakfast?
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what do you typically have for lunch?
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what do you typically have for dinner?
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what about snacks?
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Do you eat differently at weekends?
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how often do you eat fast food or takeaways?
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Do you take any supplements?
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how often do you drink alcohol?
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do you have any medical conditions that affect your ability to exercise or follow a nutrition program?
Yes
No
how many litres of water do you drink in an average day?
how many workouts do you perform in an average week?
do you have any injuries?
Yes
No
how many hours sleep do you get on an average night?
Please select...
  • 5 hours or less
  • 6 hours
  • 7 hours
  • 8 hours
  • 9 hours
  • 10 hours
  • 11 hours or more
do you drink more than 10 standard drinks per week?
Yes
No
Are you working toward a specific event or date?
Yes
No
do you eat at least one serving of fruit and 3 servings of vegetables each day?
Yes
No
do you currently smoke?
Yes
No
is your occupation sedentary?
Yes
No
how are your stress levels?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
how is your ability to focus?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
how is your memory recall?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
what are your energy levels like?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
what is your libido (sex-drive) like?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
how is your training performance?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
what is your relationship with food like?
Please select...
  • Really poor
  • Not great
  • Average
  • Good
  • Perfect
are you taking any prescription medication?
Yes
No
do you suffer from any health condition?
Yes
No
have you been diagnosed with hypertension (high blood pressure) or high cholesterol?
Yes
No
have you been diagnosed with diabetes or pre-diabetes?
Yes
No
have you been diagnosed with stress fractures, lower peak bone mass, osteoporosis or osteopenia?
Yes
No
do you suffer from, or have you been diagnosed with, heart disease, myocardial infarction (heart attack), atrial fibrillation, bypass graft or valve replacement?
Yes
No
do you have any food allergies or intolerances? if no, please write 'none'
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have you been diagnosed with kidney disease or reduced renal function?
Yes
No
do you suffer from, or have you been diagnosed with any eating disorder?
Yes
No
do you have a history of yo-yo dieting?
Yes
No
have you experienced unexplained loss of muscle and/or body fat gain?
Yes
No
have you been diagnosed with anaemia or low iron, b12 or folate?
Yes
No
have you had any gastrointestinal surgeries within the last 12 months?
Yes
No
is there anything else you would like me to know?
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Please confirm
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