Evaluation Form


    Which programme did you complete?

    How did you find the duration of your programme?


    How did you find the frequency of contact/ support?


    What did you think of the following?

    Video / audio quality

    Resources

    Programme schedule

    Communication / reports

    Value for money

    Therapeutic discussions



    What have been the three most useful things that you have taken from working with me?

    Is there anything that you wish was covered better or you feel like you would like to do more work on?

    Any other thoughts/ feedback that you would like to share with me:

    Thank you so much for your time completing this. I will value your feedback and take it on board to make sure that I offer the best and most useful service for my future clients.

    I have read and accept the privacy statement


    Hunger-Body-Mind Connection

    A variety of sensations including rumbling, gurgling, gnawing, or emptiness. While this is a common way of experiencing hunger, there are many people who do not experience hunger signs in their stomach

    Dull ache, gnawing

    Cloudy thinking, light-headedness, and headache, difficulty focusing and concentrating. Experiencing more thoughts about food and eating.

    Waning, perhaps even to the point of sleepiness. There can be dullness and even apathy towards doing anything

    Irritability and crankiness. Perhaps you have to work harder to refrain from snapping, even though you don’t present irritable to the others.

    Overall lethargy

    0 Painfully hungry. This is ‘primal hunger’, which is very intense and urgent
    1 Ravenous and irritable. Anxious to eat
    2 Very hungry. Looking forward to a hearty meal or snack
    3 Hungry and ready to eat, but without urgency. It’s a ‘polite’ hunger

    4 Subtly hungry, slightly empty
    5 Neutral. Neither hungry nor full
    6 Beginning to feel emerging fullness
    7 Comfortable fullness. You feel satisfied & content

    8 A little too full. This doesn’t feel pleasant, but it has not quite emerged into an unpleasant experience
    9 Very full, too full. You feel uncomfortable, as if you need to unbutton your trousers or remove your belt
    10 Painfully full, stuffed. You may feel nauseous


      Using the hunger scale above, at which rating do you usually FEEL the sensations of hunger?

      By the time your honour your hunger, does your hunger experience tend to be:

      pleasantunpleasantneutral

      Morning

      Time

      Hunger rating

      Quality of hunger

      pleasantunpleasantneutral

      Comments

      Mid-morning

      Time

      Hunger rating

      Quality of hunger

      pleasantunpleasantneutral

      Comments

      Mid-day

      Time

      Hunger rating

      Quality of hunger

      pleasantunpleasantneutral

      Comments

      Afternoon

      Time

      Hunger rating

      Quality of hunger

      pleasantunpleasantneutral

      Comments

      Evening

      Time

      Hunger rating

      Quality of hunger

      pleasantunpleasantneutral

      Comments

      Thank you for taking time to complete this assessment questionnaire. The assessment will help me decide what we may need to explore in a greater detail and what changes would make the biggest difference.

      I have read and accept the privacy statement


      Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


      Sleep Assessment


        What is your usual?


        How long (in minutes) does it usually take you to fall asleep?

        How many hours of actual sleep do you get at night?

        This may be different from the number of hours spent in bed

        What is your sleep efficacy?

        This is your hours spent sleeping divided by hours spent in bed

        How would you rate your sleep quality overall?

        How often have you taken medicine to help you sleep?

        (prescribed or over-the-counter)

        How often have you had trouble staying awake while driving, eating meals or engaging in social activity?

        Thank you for your time.

        I have read and accept the privacy statement


        Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


        GM Diversity Assessment

          How diverse is your gut microbiota?

          1. How many portions of vegetables did you typically eat each day?

          ( 1 portion= 1/2cup/125g cooked vegetables or 1 cup of raw vegetables)

          2. How many portions of fruit did you typically eat each day?

          (1 portion= 1 medium piece, 2 small pieces, 1 cup diced, or 1 ounce/ 30g dried)

          3. How many portions of nuts or seeds did you typically eat each week?

          (1 portion= 1 ounce/30g nuts or 1 tablespoon of seeds)

          4. How often did you eat legumes such as canned beans, lentils, chickpeas, split peas and dried beans each week?

          5. How often did you eat a high fibre breakfast cereal (i.e. bran, oats) each week?

          6. How often did you choose whole-grain pasta and brown/ wild rice instead of white pasta and white rice?

          7. How often did you choose whole-grain bread/ crackers/ wraps instead of white varieties?

          8. How often did you eat other whole grains (not included in the above; e.g. quinoa, buckwheat, freekeh) each week?

          Thank you for your time.

          I have read and accept the privacy statement


          Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


          PCOS Assessment


            Part 1: Clinical Information

            When were you diagnosed with PCOS?

            Do you have irregular or absent periods?

            yesno

            If you have irregular periods, please could you describe their pattern (if any) and associated symptoms?

            Do you have excessive body/facial hair?

            yesno

            Do you suffer with acne?

            yesno

            Could you please list any medications that have been prescribed for the management of PCOS?

            Are you taking any over the counter medications or supplements?

            yesno

            Do you have any other medical conditions?

            yesno

            Have you had any recent blood tests?

            yesno

            Attach blood results file (8mb max)

            What are your goals?

            Part 2: Dietary & Lifestyle Assessment

            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.

            Diet

            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.

            If you keep a food diary or use an app for this, you can upload it here, if you wish.(8mb max)

            Allergies & intolerances

            Your relationship with food.

            Please tick any of the below if it applies to you:

            I usually describe a day of eating as either good or badIf I eat dessert, I make plans to exercise moreOnce I eat a forbidden food, I think, I blew it, and then I eat whatever I want, 
usually in large quantitiesI feel guilty if I don’t do my usual levels of exerciseIf I am planning to go out for dinner/ drinks, I cut back how much I eat during 
the day, regardless of my hunger and fullness levelsI will not let myself eat a particular snack/ meal if it exceeds a certain number 
of caloriesI weigh myself frequently

            Alcohol

            How many units of alcohol do you drink per week? If you are unsure, please use this link to help you Drink Aware

            Smoking

            Do you smoke?

            yesno

            Thank you for taking time to complete this assessment questionnaire. The assessment will help me decide what we may need to explore in a greater detail and what changes would make the biggest difference. We will build on this during the initial appointment and you will have an opportunity to expand on any of the above and also tell me about anything else that is important to you and how you would like to move forward.

            I have read and accept the privacy statement


            Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


            Stress Assessment


              1. In the last month, how often have you been upset because of something that happened unexpectedly?

              2. In the last month, how often have you felt that you were unable to control the important things in your life?

              3. In the last month, how often have you felt nervous and stressed?

              4. In the last month, how often have you felt confident about your ability to handle your personal problems?

              5. In the last month, how often have you felt that things were going your way?

              6. In the last month, how often have you found that you could not cope with all the things that you had to do?

              7. In the last month, how often have you been able to control irritations in your life?

              8. In the last month, how often have you felt that you were on top of things?

              9. In the last month, how often have you been angered because of things that happened that were outside of your control?

              10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

              Thank you for your time.

              I have read and accept the privacy statement


              Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


              Gut-Brain Axis Assessment


                1. I worry that whenever I eat during the day, bloating and distension in my abdomen will get worse

                2. I get anxious when I go to a new restaurant

                3. I often worry about the problems in my gut

                4. I have a difficulty enjoying myself because I cannot get my mind off of discomfort in my gut

                5. I often fear that I will not be able to have a normal bowel movement

                6. Because of fear of developing abdominal discomfort, I rarely try new foods

                7. No matter what I eat, I will probably feel uncomfortable

                8. As soon as I feel abdominal discomfort, I begin to worry and feel anxious

                9. When I enter a place I haven’t been before, one of the first things I do is to look for a bathroom

                10. I am constantly aware of the sensations in my gut

                11. I often worry that the discomfort in my gut could be a sign of a serious illness

                12. As soon as I wake up, I worry that I will have discomfort in my gut during the day

                13. When I feel uncomfortable sensations in my gut, it frightens me

                14. In stressful situations, my gut bothers me a lot

                15. I constantly think about what is happening inside my digestive tract

                Thank you for your time.

                I have read and accept the privacy statement


                Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


                Gut Functioning Assessment

                  Abdominal pain

                  Any kind of pain in your gut


                  Heartburn

                  Burning/ discomfort behind the breastbone


                  Acid reflux

                  Taste of sour fluid in your mouth


                  Nausea

                  Feeling sick


                  Loud noises/ gurgling in your abdomen


                  Abdominal bloating

                  Feeling of swelling in the abdomen other than after a large meal


                  Abdominal distension

                  Belly sticking out/ “looking pregnant”


                  Belching

                  Bringing up gas through your mouth


                  Excess flatulence

                  Releasing gas more than 20 times a day


                  Constipation

                  Infrequent, hard to pass and dry faeces


                  Diarrhoea

                  Very frequent, watery or mushy faeces


                  Urgency

                  Needing to rush to the toilet


                  Incomplete emptying

                  Feeling like you are not able to pass all faeces


                  Tiredness

                  Despite regularly getting 7 to 9 hours of sleep


                  Stools

                  Referring to the Bristol Stool Chart, please describe the types of stools that you tend to have and the frequency of each type.

                  Bowel patterns

                  Please describe the time of day that you usually open your bowels and whether you have any associated symptoms, e.g. pain/ discomfort, straining etc.

                  Stool size

                  Small (less than 1 egg), medium (1-2 eggs) large (more than 2 eggs)

                  Thank you for your time.

                  I have read and accept the privacy statement


                  Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


                  Happiness Assessment

                    How happy are you?

                    When completing this assessment, it’s best not to take too long thinking about each question. The first answer that comes into your head is probably the right one for you. If you find some of the questions difficult, give the answer that is true for you most of the time.

                    1. I don’t feel particularly happy with the way I am.
                    2. I feel that life is very rewarding.
                    3. I am very satisfied about everything in my life.
                    4. I don’t think I look attractive
                    5. I find beauty in some things
                    6. I can fit in everything I want to
                    7. I feel fully mentally alert
                    8. I do not have particularly happy memories of the past

                    Thank you for your time.

                    I have read and accept the privacy statement


                    Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


                    Pre-appointment Assessment Questionnaire


                      Your weight and height

                      Please record your recent weight and height

                      Bloods

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

                      Medications

                      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)

                      Diet

                      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.

                      I have read and accept the privacy statement


                      Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.