Nutritional Analysis
Email *
Name & Surname
E-mail address
Contact number
Dietary Components
How often do you consume Sugars & Sweeteners
Once a day
More than once a day
Once a week
More than 3 times a week
Occasionally
Not at all
Sugar White
Sugar Brown
Artificial Sweeteners
Honey
Natural processed sweeteners such as stevia, xylitol
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How often do you consume grain and legume products
Once a day
More than once a day
Once a week
More than 3 times a week
Occasionally
Not at all
Bread
Pasta
Biscuits, cakes, baked goods
Sauces, processed products that contain wheat
Gluten free products
Ancient grains
Legumes
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How often do you consume Dairy (Milk,Cheese,Yogurt,Ice cream)
More than once a day
One a day
Once a week
More than 3 times a week
Less than once a week
Not at all
Milk (Full, low or fatfree)
Cheese
Yogurt
Ice cream
Clear selection
How many of the above you selected are free range or organic? *
How often do you consume Meat and alternatives?
More than once a day
Once a day
Once a week
More than 3 times a week
Less than once a week
Occassionally
Not at all
Red Meat
Chicken
Fish
Pork
Ostrich
Processed Meats (Sausage, cold cuts)
Biltong, dried or cured meats
Game
Are any of the above you consume free range, grass fed
Eggs
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How many servings of Fruit and Vegetables do you eat each day?
More than once a day
Once a day
Once a week
More than 3 times a week
Less than once a week
Occasionally
Not at all
Citrus Fruits (orange, naartjies, lemons etc.)
Tropical Fruits (pineapple, paw paw etc.)
Stone Fruits (peaches, plums, apples etc.)
Leafy greens (kale, spinach etc.)
Root Vegetables (potato, butternut,carrots)
Berries
Raw vegetables (Salads)
Are any of these organic
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Which of these Fats do you consume ?
More than once a day
Once a day
Once a week
More than 3 times a week
Less than once a week
Occasionally
Not at all
Olive oil
Olive oil Virgin Cold pressed
Coconut oil
Organic virgin Coconut oil
Grapeseed oil
Sunflower oil
Canola oil
Chia seeds
Flax seeds
MCT oil
Clear selection
What foods do you dislike or don't eat ?
Which foods do you love ?
Do you have any food allergies?(Foods when consumed is life threatening)
Do you have any food intolerances?
How many meals do you have daily?
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How much water do you drink in a day?
Less than 500ml per day
1500ml per day
More than 1500ml per day
Filtered or Distilled
Tap water
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Which beverages do you drink?
More than once a day
Once a day
Less than once a day
Once a week
Once or twice a month
Not at all
Tea black
Tea Herbal (incl. Rooibos)
Coffee
Alcohol (Beer, Spirits, Wine)
Hot chocolate, Milo, Horlicks
Fruit juice
Soda drinks
Other
Clear selection
Dietary Factors