Email *

Phone *

What sex were you assigned at birth *

Current Weight (KG) *

Height (cm) *

Daily Water Intake *

Average sleep per night *

Is your occupation sedentary *

Days of Exercise Per Week *

What is your relationship with food like? *

Do you ever experience periods of uncontrolled eating, and guilt/shame associated with it *

Are there any food groups you are intentionally avoiding? If so why?  *

What is your broad approach to food? *

How are your stress levels? *

How is your ability to focus? *

How is your memory recall? *

What are your energy levels like? *

What is your libido like? *

How is your training performance? *

Have you had recent bloodwork conducted? *

Are you on any medication?

Have you been diagnosed with kidney disease or reduced renal &? *

Do you suffer from any health condition?

If yes to above please state 

Do you suffer from or have been diagnosed with any eating disorder? *

Have you been diagnosed with hypertension or high cholesterol? *

Do you have a history of yoyo dieting? *

Please provide weight history(6-month increments for last 3 years) if yes to above How many attempts of weight loss were undertaken during this period? *

Have you been diagnosed with either 1, 2 or pre diabetes? *

Have you experienced unexplained loss of muscle and bodyfat gain? *

Have you been diagnosed with stress fractures, lower peak bone mass, osteoporosis or osteopenia? *

Have you been diagnosed with anaemia, or low iron, b12 or folate? *

Do you suffer from, or have you been diagnosed with heart disease, myocardial infarction (heart attack), atrial fibrillation, bypass graft, or valve replacement? *

Have you had any gastrointestinal surgeries within the last 12 months? *

Are you on contraception? *

Do you have amenorrhoea (irregular or absent menstrual cycle)? *

Are you, or have you been pregnant within the last 6 months? *

Have you been diagnosed with PCOS or Endometriosis? *

Have you reached menopause? *

Do you have any food allergies or intolerance? *

If yes to above list down to what foods 

If yes to above how frequent are IBS symptoms per week? What do you currently do to manage this?