Nutrition Intake Questionnaire

Please fill out the form below using as much detail as you can.

    1. Personal Information

    2. Health & Medical History

    Have you ever been diagnosed with any of the following? (please tick or list)

    3. Hormonal & Reproductive Health (If applicable)

    Are your menstrual cycles regular?

    Do you experience PMS, cramps, heavy bleeding, bloating, or mood changes?

    Are you peri-menopausal or menopausal?

    Are you currently pregnant or breastfeeding?

    Do you have a history of hormonal imbalances?

    4. Digestive Health

    How often do you experience?

    How many bowel movements do you typically have per day or week?

    5. Energy, Sleep & Stress

    How would you rate your energy levels during the day (1–10)?

    Do you experience energy crashes?

    How many hours do you sleep per night?

    Do you wake up feeling refreshed?

    How would you rate your stress levels (1–10)?

    6. Your Goals

    What are your main goals? (tick all that apply)

    7. Activity & Exercise

    If yes please describe the type and your routine

    8. Current Eating Pattern

    What does a typical day of eating look like?

    How many litres of water do you drink per day?

    9. Food Preferences

    10. Emotional & Behavioural Eating

    Do you eat when stressed, bored, sad, or tired?

    Do you struggle with:

    What times of day are hardest for you with food?

    11. Previous Dieting History

    Have you followed diets before? (e.g. keto, slimming clubs, fasting, etc)

    12. Practical Lifestyle Factors

    13. Motivation & Support

    How confident do you feel about making changes (1–10)?

    14. Anything Else