Nutrition Questionnaire

Fill in this questionnaire at anytime but the sooner the better. Be as detailed as possible to give us as much info to work from. Your evolutionary and our nutrition coach will review it and contact you if we feel we can offer some positive suggestions to create optimal health.

Contact Details

Please fill in your contact details.

Firstname:*
Surname:*
Phone - Mobile:*
Email:*
Gender:*	Please Select Male" Female"

Q 1: Which KLIK (group) do you belong to ?

Please select -------------------- Balmain - SYD - Mike Britton Balmoral - SYD - 7:15am Balmoral - SYD - 9:15am Balmoral - SYD - Rod Cotty Bondi - SYD - 7:15am Bondi - SYD - 9:00am Bondi - SYD - Aaron Laurence Bronte - SYD - 7:15am Bronte - SYD - 9:00am Bronte - SYD - Matt Buckland Coogee - SYD - 7:15am Coogee - SYD - 9:00am Coogee - SYD - Jayne McPherson Maroubra - SYD - Tom Powell North Sydney - SYD - Nick Cooper Paddington - BRIS - Amy Bridle Queens Park - SYD - Sam Hannaford Rosebay - SYD - Cam Gerrie Rozelle - SYD - Mike Britton Rushcutters - SYD - 7:15am Rushcutters - SYD - 9:00am Rushcutters - SYD - Rob Meneses

Nutrition

Q 2: Describe each meal (up to 6), including snacks, that you have in a typical working day? Try to describe portion size, cooking method, time of day.
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Q 3: Describe each meal (up to 6), including snacks, that you have in a typical weekend day? Try to describe portion size, cooking method, time of day.
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Q 4: How much water do you drink per day (in litres)?

Please select -------------------- <0.5 Ltrs 0.5-1 Ltrs 1-1.5 Ltrs 1.5-2 Ltrs 2-2.5 Ltrs 2.5+ Ltrs

Q 5: What other drinks do you consume in a day (include tea, coffee, sodas, energy drinks, fruit juice etc)?

Q 6: How much alcohol do you consume in a week?

Q 7: Do you smoke?

Please select -------------------- Yes No

Q 8: If yes, how many per day?

Please select -------------------- 1-5 6-10 11-15 16-20 20+

Q 9: How would you rate your energy levels on a scale of 1-10? (10 being high)

Please select -------------------- 1 - No Energy 2 3 4 5 6 7 8 - Energised 9 10 - Over energised

Q 10: How would you rate your stress levels on a scale of 1-10? (10 being high)

Please select -------------------- 1 - Never stressed 2 3 4 5 6 7 8 9 10 - Highly stressed

Medications and Supplements

Q 11: Do you take any medications? If yes, please list them.
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Q 12: Do you take any nutrition supplements? If yes, please list the name of each supplement and dose you take.
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Anthropometry

Please provide the following details if you know them:

Q 13: Height (cm)

Q 14: Weight (kg)

Q 15: Waist circumference (cm)

Q 16: Wrist circumference (cm)

Q 17: Have you recently lost weight or gained weight without trying? Please describe.

E.g. I have gained 10 kilograms in the past 2 months.

Medical

Q 18: Do you have any actual or suspected food intolerance? If so please list them.
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Q 19: Do you have any food allergies? If so please list them.
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Q 20: The following is a list of common medical conditions that can often be managed with dietary modifications and nutrition therapy.
Please check the box where appropriate.
	Coeliac disease
	Constipation
	Diabetes
	Diarrhoea
	Heartburn / reflux
	High blood pressure
	High cholesterol
	Irritable Bowel Syndrome
	Poly-cystic ovarian syndrome (PCOS)

Q 21: Do you have any other medical conditions?

Pregnancy

Q 22: Please check the box if any of the following apply to you:
	I am pregnant
	I am breastfeeding
	I am trying to conceive

Goals

Q 23: What is the main thing you hope to achieve by getting nutrition advice?

Q 24: Do you have a goal weight? If so what is it (kg)?

Q 25: Set a realistic date for achieving your goal by?

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