Dublin Dietitian Screening Form
Welcome to the first step to see which program program is right for you! Please provide as much detail as possible so I can serve you effectively during our online session. ~Kate C.
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What Is your full name? (first and last) *
Today's Date *
MM
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DD
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YYYY
What is your Primary Goal? *
Just the TOP issue, highest priority to you
What are your Secondary Goals *
Select all that apply
Required
Which of the following do you experience at least on a monthly basis? *
Required
Which of the above ones are most severe and/or most frequent? (several times a week) *
What, if any, diagnoses or health issue do you have? *
What medications are you currently taking, and how often do you take them? (over the counter, and/or prescription)
What is your current nutrition and exercise routine? *
E.g. Weight Watchers, FODMAPS, AIP, 5:2, P90X, PT... 20 Minute home workout Monday, Wednesday, Thursday with a 1 hour run on the weekend. Nutrition: Breakfast = 2 x eggs, Lunch = Sandwich with ham and cheese + crisps, Snack = chocolate bar, Dinner = Pasta with bacon and cheese, Pre-bed snack = rice cakes
How would you rate your stress levels? *
Absolutely no stress
I'm ready to break
Which describe your sleep? Choose any that apply. *
Required
What are your health and fitness goals over the next 90 days (Include current body weight and goal body weight if applicable; any symptoms that are bothering you that you would like resolved)? *
Why have you decided to reach out about this NOW? *
On a scale of 1-10 (10 being the highest), how committed are you about achieving your goals? *
Low
High
HONESTLY, why haven't you reached these goals already? What are your barriers? *
What else have you tried to do to solve this? *
Which is the bigger struggle for you? *
Please elaborate on the prior question.
Are you prepared to invest financially to get the results you want and deserve, knowing you have guidance and support from a medical professional and expert in the field? *
How did you hear about Kate and Dublin Dietitian? *
If personal referral, who referred you?
What is your email address? *
What is your best contact number (Including International Dial Code) *
What is your time zone? *
Anything else you would like me to know before we talk? *
Thank you! Watch your inbox for a few follow up notes and some FAQs from my email, Kate@DublinDietitian.com. (Keep an eye on your Junk folder - it winds up there some times) Have a great day! ~Kate
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