On completing this review, we shall get straight to work on working out how to help you with your personal heath and wellness challenges.

Contact Information

Personal Information

Exercise and Health Conditions

Please tell us any exercise or sports activities you may engage in regularly.

What is your current energy level? 0 being very low, 10 being very high.

What form of exercise do you enjoy? IE, Classes, Running, Cycling etc.

What form of exercise do you NOT enjoy? IE, Classes, Running, Cycling etc.

Do you have any injuries? IE, damaged knees/joints, torn ligaments.

Please tell us all the health conditions you currently suffer.

Are you currently, or planning to take any medication. If YES, please provide.

Current Nutrition

Please tell us a little about your current nutrition.

Typical breakfast for:

Typical midmorning snack for:

Typical lunch for:

Typical mid afternoon snack for:

Typical dinner for:

Typical late evening snack for:

What do you like to snack on and how often a day. IE Fruit, Chocolate, Biscuits:

What vegetables do you eat a day and how many portions:

What fruit do you eat a day and how many portions:

How many glasses of water do you drink a day?

How many units of alcohol do you consume a week?

What other types of drink do you consume? IE Coffee, Fizzy drinks.

What types or Takeaway/Restaurant do you like and how often a week?

Do you eat fish and if so, how often a week?

Do you take any nutritional supplements?

If yes, what supplements do you take?

Eating Habits

Where do you typically eat your food? IE Dinner table, on the sofa watching TV.

How fast or slow do you eat?

How compelled are you to finish you plate? 0 being not very, 10 being very high.

Are there any eating habits you feel you may have? IE Cravings, Craving your can not control, eating when upset.

Sleeping Habits

How well do you sleep? 0 being very low, 10 being very high.

How many hours sleep per night do you get?

General Notes or Concerns

Please use the below to tell us about any concerns you may have about your heath or any notes you feel relevant.

Finally, what is your goal at the end of this? (i.e, more confident, feel healthier etc)