Please answer all the questions below as honestly and accurately as possible Don't worry if you're not quite sure, we can explore anything further with you.

Name

First Name

Last Name

Date of Birth

YYYY

Occupation *

How much do you work? *

Full Time

Part Time

Casual

Other

Current Weight *

Height

Waist circumference

MEDICAL

Medical History

Do you have any of the following?

High blood pressure

Diabetes

High cholesterol

Fatty liver

Heart attack

Stroke

Heartburn or reflux

Asthma

COPD

Obstructive sleep apnoea

Hormonal issues

Low libido & other sexual problems - to elaborate further during consultation with GP

Depression

Anxiety

Sleep disturbance

Needle phobia

Surgical History *

List previous operations

Alcohol

On average, how many drinks do you have a week?

Cigarette Smoking *

Do you smoke? if so how many a day?

Cannabis *

Do you use cannabis? (medicinally or recreationally)

Are you currently taking any medications or supplements? List the name, dosage and how long you have been taking the for. *

Is there any significant family medical history of illnesses or disease? Please list condition and which family members *

Previous weight loss attempts *

List program or strategies

NUTRITION

Do you have any food intolerances, allergies or sensitivities? Please tick any that apply

Diary

Gluten

Wheat

Yeast

Fish

Shellfish

Tomatoes

Nut

Citrus Fruits

Eggs

Garlic

Onion

Preservatives

Colours

Flavours

Amines

Salicylates

Other

Do you suffer from any of the following conditions?

Bloating

Heartburn / Reflux

Constipation

Diarrhoea

Undigested food in stools

Parasites / Worms

Angina

High Blood Pressure

Low Blood Pressure

High Cholesterol

Dry Skin

Dandruff

Eczema

Ringworm

Dermatitis

Oily Skin

Acne

Psoriasis

White spots on nails

Flaky

Brittle nails

Hair Loss

Heavy menstrual periods

Irregular menstrual periods

Short periods (less than 25 days)

Long periods (longer then 33 days)

Premenstrual Symptoms (PMS)

Low Libido

Thrush

STI's and STD's

Erectile dysfunction

Memory loss

Night Sweats

Cold hands and feet

Brain Fog/ vague

Anxiety

Depression

Muscle pain or spasms

Dizziness

Migraines

Hayflever

Allergies

UTI's (recurrent)

Asthma

Recurrent colds and flus

How much water do you drink per day?

Do you drink tea and coffee or energy drinks? If so how many per day?

How many meals and snacks do you eat per day

List which foods you DON'T enjoy eating

List which foods you DO enjoy eating

How would you describe your lifestyle in terms of health *

Are you currently undertaking any sports? if yes please describe (type, duration and inc. trainings)

What is your general energy level out of 10 throughout the day? 10 being very energetic

How do you rate your stress levels throughout the day? 10 being very stressed

What short term goals do you wish to achieve with this nutritional advice?

Are there any reasons that you think you may not achieve your goals? (cost, time, support, work commitments)

What do you eat for breakfast? Please provide as many options as possible

What do eat for lunch? Please provide as many options as possible

What do you eat for Dinner? Please provide as many options as possible

What do you eat as snacks throughout the day and after dinner? Please provide as many options as possible *

Is there any other information regarding your lifestyle that you think will assist with preparing your nutrition program? *

What do you hope to achieve by participating in this program?

Thank you for taking the time to fill in the required information prior to your appointment.

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Mode Healthcare acknowledges the Traditional Custodians, the Wadandi people, on whose land we are living, and pay our respects to Elders, past, present, and emerging.
Medical Disclaimer: Information provided by Mode Healthcare is for educational and informational purposes only. For medical advice, please refer to your doctor.
Medication in Australia is regulated by the Therapeutic Goods Administration and details about scheduled drugs can be found on their website.