Nutrition – Initial Consultation Form

    We appreciate the opportunity to serve you and ask you to assist us by completing the following questions.

    Are you under 18 years old? YesNo
    How did you hear about us? Have you ever received nutritional care? YesNo

    Your Health History

    About Your Life Journey

    The human body is designed to be healthy. Throughout the course of your life's journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they have likely had an accumulating effect on your life and health. Please answer the following questions regarding your life's journey.


    Did your Mum and Dad... Prepare their body for pregnancy? YesNoUnsure Plan and welcome the pregnancy Have a nutritious diet during pregnancy? Exercise through pregnancy? YesNoUnsure Smoke or drink alcohol during pregnancy? YesNoUnsure Endure stress during pregnancy? YesNoUnsure Have any scans? YesNoUnsure

    Birth Process

    Home birth? YesNoUnsure Hospital birth? YesNoUnsure Induced labour? YesNoUnsure Was your birth... EarlyLateOn due dateNot sure Drugs during delivery? YesNoUnsure Long delivery? YesNoUnsure Difficult delivery YesNoUnsure Caesarean (elective/emergency)? YesNoUnsure

    Childhood Growth and Development


    Did you reach all your milestones? YesNoUnsure Did you have any major accidents? YesNoUnsure Did you have any surgery? YesNoUnsure Did you play childhood sports? YesNoUnsure


    Take medication/drugs? YesNoUnsure Were you breast-fed? YesNoUnsure

    For how long?
    Were you bottle fed? YesNoUnsure
    For how long?
    Vaccines received? YesNoUnsure Were you taught about healthy eating? YesNoUnsure Were you a fussy eater? YesNoUnsure Did you ever have an eating disorder? YesNoUnsure


    Was there any stress in the family? YesNoUnsure Was there a loss of a family member/relative? YesNoUnsure Was there communication breakdown in the household? YesNoUnsure

    If yes to any of the above, please give details


    Do you eat healthy foods? YesNoUnsure Do you smoke? YesNoUnsure Do you drink alcohol? YesNoUnsure Do you drink adequate water? YesNoUnsure Do you drink any caffeinated drinks? YesNoUnsure Are your teeth healthy? YesNoUnsure Do you sleep well? YesNoUnsure Are you physically stressed? YesNoUnsure Are you mentally stressed? YesNoUnsure Are you taking or have you ever taken drugs/medication? YesNoUnsure Do you exercise regularly? YesNoUnsure

    General Health

    Family History cancer/diabetes/cardiovascular disease/other? YesNo

    Eating Habits

    Please complete the 3 day Food Diary (download available on top of this page), and email it back to us at a few days prior to your initial visit.

    Health Goals

    People consult us with one or more of the following health goals. Please indicate which apply to you.