Eating Plan Questionnaire

PERSONAL DETAILS

Name ^*

Email ^*

Phone ^*

Gender
Male
Female
Other

Date Of Birth

CURRENT MEDICAL STATUS

Do you have a diagnosed medical condition?

If Yes, what medical condition do you have?

Are you pregnant?

If you are pregnant, how many weeks?

Are you taking any prescription medication?

If you are taking prescription medication, what are you taking?

FAMILY HISTORY

Do you have a family history of disease?

If you have a family history of disease, what disease/s?

MEASUREMENTS

Current weight (kg)

Height (cm)

Weight you would like to be (kg)

When last did you weigh your desired weight?

DIETING HISTORY

Have you tried to lose weight or change your dietary habits?

If you have tried to lose weight or change your dietary habits, what did you do? Taken Medication
Used a Diet Book
Internet Diet
See a Dietician

Please elaborate on your diets if you feel it would assist us

EXERCISE

Are you exercising?

Excercise Type

Excercise Frequency (times per week)

DIETARY RECALL

Please detail an example of 1 day of your current eating habits

FOOD PREFERENCES

Please list any foods you do not eat or do not like

GOAL

What is your ultimate GOAL and why have you ordered this Personalised Eating Plan?

DISCLAIMER

The information given to you in your Personalised Eating Plan is educational in nature and intended for healthy people. Kelly Lynch Dietician will not be held liable for any illnesses, misunderstandings or misinterpretations caused whilst following the plan. The plan is a general guideline and Kelly Lynch Dietician always recommends a one-on-one consultation over an online plan.
Please note: Your information will only be processed on completion of successful payment.

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