Pre-Nutrition Assessment Form

Please complete this form before your consultation. Your answers help your dietitian understand your current health, eating pattern, lifestyle and nutritional needs before your appointment.

1. About You

First name

Last name

Date of birth

Month

Day

Year

Email

Phone number

Height (cm)

Current weight (kg)

Main reason for seeing the dietitian

General nutrition

Weight management

Women's health or menopause

Diabetes or prediabetes

High cholesterol or high triglycerides

High blood pressure

Gut health

Osteoporosis or bone health

Cardiovascular or heart health

Fatty liver or metabolic-associated fatty liver disease

IVF or fertility

Pregnancy

Postnatal or breastfeeding

Body composition or healthy ageing

Other

Pre-Nutrition Assessment Form