Distance Nutrition Support - Karli
PLEASE NOTE: If you are filling out this form, it means you wish to purchase our nutrition service. If this is not what you want to do, just delete the tab, no harm done.

Please answer all of the following questions. This will allow us to prepare for our first consultation. You will need to have a good internet connection to participate in this service.

Ensure you read the bottom section that outlines the terms and conditions and client rights.

Name *
Your answer
Email (this will be used to contact you) *
Your answer
Contact phone number *
Your answer
Age *
Your answer
Weight (kg) *
Your answer
Height (cm)
Your answer
What is your waist size (It doesn't matter how you measure, as long as you do it the same next time)
Your answer
Gender *
What is your main reason for coming to see us? (e.g. for more energy, weight loss etc.) *
Your answer
Select the activity level that best describes you now. *
Diet History
The purpose of this section is to gather information about your current diet. We understand it can be difficult to remember too much detail around diet as it is such a habitual activity, however it is important that this be as accurate as possible, as this will allow us to provide the best possible service to you.

When considering your answers, think about what you have usually eaten over the past one to two months.
Try to include portion sizes and time of day wherever possible, and specify whether etc milk is trim or full-fat, any sugars in drinks, and type of bread eaten, if any.

Breakfast - Two slices of toast-sliced white bread with margarine and marmite, coffee with two sugars and trim milk.
Morning tea - Blueberry muffin with butter and a flat white with one sugar.
Lunch - Two x fist sized mashed potato (made with butter and full fat milk) with a hand sized steak and an apple.

Enter 'N/A' if you have no food at these times.

Describe your usual breakfast, including drinks.
Your answer
Describe any morning snacks, including drinks.
Your answer
Describe your usual lunch, including drinks.
Your answer
Describe any afternoon snacks, including drinks.
Your answer
Describe your usual dinner meal, including any drinks and condiments.
Your answer
Describe what you have to eat after dinner - include approximate portion sizes if possible, and drinks.
Your answer
How does the food you eat on the weekend differ from the food you eat during the week? Include drinks.
Your answer
If you feel any foods or drinks you regularly consume have been missed, please describe:
Your answer
Do you feel that you ever have periods of over-eating in response to your mood or environment? Elaborate as much or as little as you wish.
Example: Had a stressful day at work and pick up takeaways on the way home
Your answer
How motivated do you feel to make changes to your diet?
Not at all motivated
Extremely motivated
How confident do you feel that you will be successful at making changes to your diet?
Not at all confident
Extremely confident
What do you see as the advantages of changing your eating?
Example: To feel in control and more energetic
Your answer
Do you have any medical conditions? If so, please specify.
Your answer
Are you currently on any medications? If so, please specify.
Your answer
Do you have any food allergies or intolerances? If so, please specify.
Your answer
Our terms and conditions
Please read these Terms and Conditions carefully before submitting the questionnaire. By accessing or using our service you agree to be bound by these Terms. If you disagree with any part of the terms then please do not submit your questionnaire. All of our nutrition team are fully qualified nutritionists or dietitians. However, our team are not medical doctors and the scope of our consultation services does not include clinical treatment or diagnosis of specific illnesses or disorders. Our recommendations are purely from a green prescription perspective (nutrition and exercise) and our services do not include advice about medication and prescription drugs. Before undertaking any exercise, it is up to the responsibility of the client to seek clinical advice from a medical practitioner. While people will experience greater health and wellness as a result of following our recommendations it does not promise or guarantee protection from future illness and/ or attainment of personal goals.

If for whatever reason you are unable to connect to your appointment, give your dietitian/ nutritionist at least 12hrs notice. Failure to do soon could lead to forfeiture of appointment without refund.

In all most all situations there will be no refunds unless you feel you your circumstances are extraordinarily special. This judgement will be up to your dietitian/ nutritionist discretion.

If you disagree with any part of the terms then please do not submit your questionnaire.

Your Rights as a Client
All client information kept by our services is maintained based on the privacy principles established under the Privacy Act, 1993. Information given or told by you to the dietitian/ nutritionist is confidential and will only be used for the following purposes:
- To enable us to provide services to you as agreed with you.
- To collect information for statistical purposes.
- To review the quality and quantity of services delivered to clients, whānau and communities.

- You have the right to pull out of the consultation at any time.
- You have the right to be treated with respect
- You have the right to have your mana completely intact throughout the whole process
- You have a right to make a complaint to be sent to nutrition@toitangata.co.nz Subject: Nutrition Service Complaint
- You have the right to access information held about you by us and to correct that information. You can do this by asking your dietitian / nutritionist.

Do not submit questionnaire if you do not understand your rights. Email nutrition@toitangata.co.nz Subject: Client rights for further clarification

Toi Tangata Nutrition Support Service
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