Initial Nutrition Pre-Consultation Form
This form helps you get clear on your goals surrounding your health, and provides me with some background information to save us time once we meet for your initial appointment. It should take around 20 minutes to fill out - if you don't have time now you can bookmark this page and come back to it later.

Please submit at least 24 hours before your booking.

If you have any questions about this form please email me at tamika@nourishednaturalhealth.com

Full name *
Your answer
Today's date *
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Gender *
Date of birth *
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YYYY
Email address *
Your answer
Home address
Your answer
Emergency contact *
Your answer
Private health fund provider (if in Australia)
Your answer
How did you hear about me? *
Occupation
Your answer
Are you happy to receive my newsletter (health tips, research, recipes)? *
Health Goals
What is your main reason for booking an appointment with me? *
Your answer
What are your 3 biggest health goals you would like to achieve? *
Your answer
How motivated are you to make these changes? *
Not motivated at all
Extremely motivated
Health History
Do you have any medically diagnosed conditions or injuries? Please list if yes
Your answer
Have you ever suffered from the following?
If you have ticked any of the above and would like to elaborate please do so here:
Your answer
Have you had any injuries, hospitalisations or surgeries in the past 6 months? Please give relevant details:
Your answer
Please list all medications you are currently taking (prescription and non-prescription/over the counter):
Your answer
Please list all supplements, herbs and vitamins you are currently taking:
Your answer
If you are taking supplements/herbs/natural remedies, please list why you are taking these, how long you have been taking them and if you feel they are helpful
Your answer
Describe what physical activity you do (this might not be what you consider ‘exercise’ – it could be any activity that you do that moves your body, raises your breathing and heart rate, or causes you to sweat e.g. dancing, going up stairs to work, gardening etc.) How often do you do these activities each week and for how long?
Your answer
Are you exposed to any of the following regularly?
Dietary Habits
How would you describe your diet? Please tick as many as apply to you
Please list any food intolerances/sensitivities/allergies, either diagnosed or suspected and what happens when you eat these foods
Your answer
Please list any foods you avoid for health/religious/ethical reasons and outline why
Your answer
Are there any foods you particularly dislike or avoid?
Your answer
Do you crave particular foods? If so which ones
Your answer
What are some of your favourite foods/cuisines?
Your answer
How confident are you are preparing your own meals from scratch using fresh ingredients at home?
No confidence
Extremely confident
How many people do you live with?
Who does most of the cooking in your household?
Your answer
Please tick if you do any of the following regularly
How would you describe your alcohol drinking habits?
What type of alcohol do you drink?
How many standard drinks of alcohol do you usually consume per week?
Your answer
How many cups of coffee do you drink each day?
Your answer
How much water do you drink per day?
Do you smoke cigarettes?
Sleep and Stress
What is your current level of stress?
Completely relaxed
Tearing my hair out
Do any of the following regularly apply to you?
How many hours of sleep do you usually get per night?
Your answer
What (if anything) do you do to relax?
Your answer
Rate your energy levels on waking
No energy
Full of energy
Rate your energy levels during the day
No energy
Full of energy
Rate your energy levels mid afternoon
No energy
Full of energy
Family Medical History
Please provide details of any illnesses of conditions in your immediate family (siblings, parents, grandparents)
Your answer
Men Only
MEN ONLY: Do you suffer from the inability to maintain an erection?
MEN ONLY: Have you noticed a change in your urine flow?
MEN ONLY: Do you have difficulty stopping and starting your urine flow?
Women Only
WOMEN ONLY: Do you currently have a menstrual cycle?
WOMEN ONLY: If you are currently taking a hormonal contraceptive, please list which one and how long you have been taking it for
Your answer
WOMEN ONLY: Do you suffer from any of the following?
DISCLAIMER:
Please write your name and today's date below to show you accept the disclaimer below:
"I understand that a nutrition consultation is not a substitute for professional medical treatment and that a Clinical Nutritionist does not diagnose medical conditions, but may help manage those already diagnosed by a medical professional through dietary and nutritional recommendations. If your presentation requires the attention of a medical practitioner and is either beyond the scope of nutritional management or requires a medical diagnosis first, treatment may be declined or discontinued, until these concerns have been addressed." *
Your answer
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