The Health Dietary Reboot Questionnaire - The Wellness Junction

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07830 018 065|stiana@thewellnessjunction.com

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About
Services
Resources
- Healthy Recipes
- Freebies
Blog
Contact
Book your Free Call

About
Services
Resources
- Healthy Recipes
- Freebies
Blog
Contact
Book your Free Call

The Health Dietary Reboot QuestionnaireStiana Hubert2020-06-22T13:32:14+00:00

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Please complete the brief questionnaire, as the information will enable me to provide you with a dietary plan specific to your needs.
Name
First Middle Last
Date of Birth

Day
Month
Year
Age
Gender
- Female
- Male
Address
Street Address Address Line 2 City County Post Code Country
Email
Home Phone
Mobile Phone
How would you rather be contacted?
- Home Phone
- Mobile Phone
- Email

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Your Weight
Your Height
Occupation
What work do you do?
How many hours do you work on average a week?
Do you work night-shifts?
- Yes
- No
Do you enjoy your work?
- Yes
- No
Do you have exposure to chemicals at work?
- Yes
- No

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Health, Lifestyle and Exercise
Please state your key health goals and what areas of your health you would like to improve.
Do you smoke?
- Yes
- No
How many cigarettes do you smoke each day?
Do you drink alcohol?
- Yes
- No
How many days a week on average do you drink alcohol, how much do you drink each day and what is your preferred drink?
Do you exercise?
- Yes
- No
How many times each week?
On average how long do you exercise for?
What type of exercise do you do?
How would you describe your current lifestyle?
- Stressed
- Happy
- Unhappy
- Busy
- Relaxed
Do you feel you can easily handle stress in your life?
- Yes
- No
What is the average number of hours you sleep each night?
- 6 or less
- 6 - 8
- 8 - 9
- 9 - 10
- 10+

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Medical History
Allergies
- Dairy
- Soy
- Wheat
- Yeast
- Gluten
- Lactose
- Artificial flavourings/colourings
- Metal Jewellery
- Plasters
- Latex
- Rubber
- Dust Mites
- Grass
- Pollen
- Fur
- Food
- Medicines
Do you suffer from any major/re-current illnesses (e.g. hepatitis, jaundice, diabetes, TB, glandular fever, asthma, herpes or shingles)? Please give details where appropriate.
Do you currently take any prescription medication?
- Yes
- No
Do you currently take any prescription medication, if so please list them below and please specify whether you experience any side effects.
Do you currently take any nutritional supplements? If so please list them in the table below and please state whether you experience any side effects.
Do you experience muscle cramps or spasms?
- Yes
- No
Do you have trouble thinking or concentrating?
- Yes
- No
Do you suffer any bloating and a sense of abdominal fullness?
- Yes
- No
Do you suffer any reflux?
- Yes
- No
How many times a day do you produce a stool?
Do you experience any pain when passing a stool?
- Yes
- No
Have you noticed any blood in your stool?
- Yes
- No
Does your stool(s) float?
- Yes
- No
Are you generally constipated, or straining during bowel movements?
Do you fluctuate between being constipated and having diarrhoea?
- Yes
- No
Do you suffer from haemorrhoids?
- Yes
- No
Do you experience any rectal itching or cramping?
- Yes
- No
Do you feel experience abdominal discomfort or nausea after eating fatty foods?
- Yes
- No
Have you had any weight change recently?
- Yes
- No
Do you suffer with eczema?
- Yes
- No
Do you suffer with psoriasis?
- Yes
- No
Do you experience urgency to urinate?
- Yes
- No
Do you experience excessive thirst?

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Have you ever had Gestational Diabetes?
- Yes
- No
Hypothyroidism
- Yes
- No
PMT
- Yes
- No
Are you in Menopause?
- Yes
- No
Do you have Weight Gain?
- Yes
- No
Do you have Joint Pains?
- Yes
- No
Rate your levels 1 - 10 (1=low, 10=high)
Rate your energy levels
Please enter a number from 0 to 10.
Rate your memory
Please enter a number from 0 to 10.
Rate your concentration
Please enter a number from 0 to 10.
Rate your general mood
Please enter a number from 0 to 10.
Rate your general well-being
Please enter a number from 0 to 10.

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Nutrition
Have you ever seen a Nutritional Therapist?
- Yes
- No
Do you currently follow a specific diet, such as Low Fat, Paleo, Vegan, Wheat Free, Dairy Free, 5:2
- Yes
- No
Please specify which and how long you have been on eating in accordance with this?
Have you made any changes to your eating habits due to health?
- Yes
- No
Please specify
Do you struggle with your weight?
- Yes
- No
Which weight loss plans/programmes have you tried and were any effective?
How often do you weigh yourself?
How would you rate your appetite?
Please enter a number from 0 to 10.
(1 = low/10 = high)
Do you enjoy food?
- Yes
- No
Do you avoid any particular foods?
- Yes
- No
Please specify and state the reason why
Do you have any specific cravings for foods?
- Yes
- No
Please state which foods
What are your favourite foods?
Who does the cooking at home?
Who does the food shopping?
Where do you buy the majority of your food?
How many times a week do you dine out?
What sort of food do you eat if you dine out?
What foods and drinks would be hardest to cut out?
How many cups of tea and coffee do you drink a day?
Do you add sugar to your drinks?
- Yes
- No
How many teaspoons?
How many glasses or volume of water do your drink each day?
Do you normally eat white bread, pasta and rice?
- Yes
- No
Do you normally eat brown bread, pasta and rice?
- Yes
- No
Do you eat/drink/use:
Candy/sweets
- Yes
- No
Refined sugar
- Yes
- No
Fizzy drinks
- Yes
- No
Fast-food restaurants
- Yes
- No
Distilled water
- Yes
- No
Fried foods
- Yes
- No
Filtered water
- Yes
- No
Deli meats
- Yes
- No
Margarine
- Yes
- No
Cordials
- Yes
- No
Artificial Sweeteners
- Yes
- No

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Please provide any additional information that you feel may be useful to support your plan.
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Please provide any blood test, test results or any other medical information that may be useful for your consultation.
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I declare that the information provided is correct and to the best of my knowledge. Please state your name and today's date:
Name
First Last
Date
Month
Day
Year
Number
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