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Eating Plan Questionnaire
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?
No
Yes
If Yes, what medical condition do you have?
Are you pregnant?
No
Yes
If you are pregnant, how many weeks?
Are you taking any prescription medication?
No
Yes
If you are taking prescription medication, what are you taking?
FAMILY HISTORY
Do you have a family history of disease?
No
Yes
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?
No
Yes
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?
No
Yes
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.
* Required Fields
SUBMIT INFO AND PAY
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