Pre consultation questionnaire

Please answer the nutritional questions below.

Name

First Name

Last Name

Current Height & Weight

Family Structure:

Married

Divorced

Single

Partner/ relationship

Children & ages

Medical Centre information - GP name and practice

please provide address

Surgical History?

Please give details of past operation

Which operation are you having?

If known

Do you have any medical conditions?

please give details

What medications are you taking?

Please state all medications that you are on, the dose, and how long you have been taking them. Please include the contraceptive pill and any herbal remedies

What supplements are you taking? (please be specific with brands, doses and consistency)

including sport or herbal supplements

How many meals do you eat daily?

Please describe your meal patterns (eg snacking, grazing)

What do you eat on a usual day for breakfast, lunch and dinner?

How much fluid are you managing to drink each day and what do you generally choose?

Are you drinking any alcohol, and if so, how often and volume how much?

Do you smoke?

Yes

Yes- but have now stopped

Never

Pre consultation questionnaire

Lose Weight.
Gain Health.
Live Life.

In Association With

Pre consultation questionnaire

Lose Weight. Gain Health. Live Life.

In Association With

Lose Weight.
Gain Health.
Live Life.