Diet Plan Questionnaire
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Full Name *
Email Address *
Address and Postcode *
Age *
Gender *
Occupation *
Marital Status *
Do you have children? *
Do you have any long-term illnesses? *
Do you experience any of the following gut problems? *
Obligatorio
Do you have any of the following allergies? *
Obligatorio
How many units of alcohol do you drink per week? *
1 unit = half a pint / glass of wine
How many loose bowel movements do you experience during day?
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Have you unintentionally lost over a stone in the last 4 months? *
Weight *
kilograms
Height *
meters
Please rate your physical activity *
days per week, 30 mins or more
Do you have a nutritional goal or aim that you are hoping to achieve with 121 Dietitian? *
How many cups of tea do you drink each day? *
How many cups of coffee do you drink each day? *
How much water do you drink each day? *
millilitres
How often do you eat take-aways? *
What take-aways do you consume? *
Obligatorio
How many hours sleep do you get? *
hours
Do you smoke? *
Is your mood usually *
Do you suffer from anxiety? *
Please select the programme you are interested in *
You can find the information on our website www.121dietitian.com
Please provide your mobile phone number in case we have to contact you about your appointment *
Would you like to be contacted by a dietitian to check up on progress in future? *
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