Initial Appointment Assessment

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

Name

Date Of Birth

Weight

Height

Do you have a recent blood test?

Yes No

Are you currently taking any medications or supplements?

Yes No

If so, what medications / supplements are you currently taking?

Other medical conditions

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 include walking or cycling to work, housework, and gardening.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How high are your levels of stress at present? (0 = no stress; 10 = very high stress impacting work/relationships)

Diet Diary

Are you avoiding any food or drinks?

Yes No

If so, which food or drinks are you avoiding? (Please record the food/drinks and the reason)

Do you have any diagnosed allergies?

Yes No

If so, what were you diagnosed with?

Your Relationship with Food

I usually describe a day of eating as either good or bad.