Your weight and height

    Please record your recent weight and height


    Have you had any recent blood tests? Please attach the report, if available. 8mb max file size


    What medications/ supplements are you currently taking?

    Other medical conditions

    What (if any) other medical conditions do you currently have?

    Current physical activity levels

    Please note down your usual planned and unplanned physical activity. Record intensity levels using L for low intensity, M for moderate & V for vigorous intensity*. Examples of unintentional physical activity include walking or cycling to work or shops, housework and gardening.

    Subjective assessment of stress levels

    How high are your levels of stress at present? (0- no stress at all; 10- very high levels of stress, impacting on work/relationships)


    Please record your usual day of eating. Please include all food and drinks. It would be helpful to understand what you usually consume at each meal and snack time.

    Are you avoiding any foods/ drinks & if so, what is the reason for it?

    Do you have any diagnosed allergies?

    Your Goals

    Please describe three goals that you want to achieve through changing your diet &/or lifestyle habits.

    Thank you for your time.

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