• First Name
• Last Name
• Date of Birth
• Email
• Phone Number
• What is the main reason for booking with our Dietitian?
• What would you like to get out of your appointment with our Dietitian?
• Have you seen a dietitian before?
  - Select a Value - YES NO
• Please list any medical conditions you have: (diabetes, cardiovascular disease, hypertension, PTSD, IBS, hypothyroidism etc.)
• Have you had any relevant surgeries?
• Are you currently on any medications? Please list:
• Do you have a family history of any chronic conditions? (obesity, diabetes, high blood pressure, high cholesterol, heart disease, thyroid disease or cancer)
• Do you have any food allergies or intolerances? Please list:
• Do you ever experience: (tick which apply)
  Constipation Diarrhoea Gas Bloating Reflux Abdominal Pain Nausea/Vomiting
• What is your current height?
• What is your current weight?
• What has your weight done over the last year?
  - Select a Value - Stable Increasing Decreasing Yo-Yo-ing
• Have you got a goal weight or dress size?
• Have you ever had any of the following eating disorders?
  - Select a Value - Anorexia Bulimia Binge Eating N/A
• Occupation
• Who does your shopping and cooking?
• On a scale of 1-10 (10 being the most stressful) how stressed are you?
• What contributes to your stress?
• Do you have any specific dietary requirements?
  Vegetarian Vegan Gluten Free Lactose Free N/A
• Do you currently engage in regular physical activity? If so, what & how often?
• What is your usual eating pattern?
  3 Meals Per Day Grazer Night Time Eater Skip Meals Exessive Snacking Eat Differently On Weekends No Pattern/Random
• What do you typically eat for breakfast?
• What do you typically eat for lunch?
• What do you typically eat for dinner?
• What do you snack on – morning tea, afternoon tea, supper?
• What triggers you to eat?
  Boredom Emotions Time Of Day Seeing/Smelling Food Social Situations Hunger
• How many times per week do you eat out or get takeaway?
• How much water do you drink per day?
• How many days per week do you drink alcohol?
• On the days you drink, how many drinks do you consume? 1 drink = approx. 285mL beer, 100mL wine 30mL spirits.
• Do you drink any of the following: coffee, tea, juice, cordial, soft drink?
• Is there any other information you would like to share?

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