Name
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First Name
Last Name
Date of Birth
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Gender
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Height (cm)
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Current Weight (kg)
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Email
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Mobile Number
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Home Number
In general, what are your goals?
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Please check all that apply.
If you answered 'Other' above, please provide details below.
How, specifically, would you like your health, your eating, and / or your body to be different?
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Out of all the changes you would like to make, which ones feel most important / urgent?
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Have you tried anything in the past (or recently) to change your habits, your health, your eating, and / or your body?
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If you answered 'Yes' to the above question, please provide further details.
If you answered 'Yes', what has previously worked well for you, and why?
Even if something only helped you a little bit, and even if you might not be doing it right now.
If you answered 'Yes', what previously didn't work well for you, and why not?
If you were to consider maybe making more changes to your habits, your health, your eating, and / or your body, what might those be?
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Until now, what has stopped you or held you back from making theses changes?
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Why did you select the number above?
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Please state your dietary requirements
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i.e. Any foods you can / will not eat.
Do you have any food allergies or food sensitivities (that cause excessive gas, bloating, headaches, rashes, stuffiness etc)? If so, please provide details below.
Do you currently take any supplements?
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If yes, please provide details.
If yes, please list them with details.
Quantities, consumption, brands etc.
How often do you drink alcohol?
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Are you regularly active in sport and / or planned exercise? If so, for how many hours per week?
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What types of sports and / or exercise do you typically do?
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Approximately how many hours per week do you spend doing other types of movement / physical activity (e.g. housework, walking to work or school, home repairs, moving around at work, gardening etc)?
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What other types of movement and / or activities do you do?
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Who lives with you?
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Please select all that apply.
Do you have children?
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If yes, how many and what are their ages?
Who does most of the grocery shopping in your household?
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Please select all that apply.
Who decides on most of the menus / meal types in your household?
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Please select all that apply.
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
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Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
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Right now, are you taking any medications, either over-the-counter or prescription?
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Why did you select the number above?
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Are you currently postpartum, lactating or trying to conceive?
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Please check all that apply.
FEMALES ONLY. Please detail information relating to your menstrual cycle length and frequency or if you are postmenopausal.
In an average week, how many hours do you spend in paid employment / doing self-employed work
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In an average week, how many hours do you spend at School / College / Uni or doing School / College / Uni work?
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In an average week, how many hours do you spend traveling and / or commuting?
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In an average week, how many hours do you spend taking care of others?
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In an average week, how many hours do you spend doing unpaid work (e.g. housework, errands)?
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In an average week, how many hours do you spend volunteering?
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On average, how many hours per night do you sleep?
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PLEASE SELECT
4 or fewer hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How do you normally cope with your stress?
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What do you expect from us at Aristos Nutrition?
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What does success look like to you?
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Please recognise that it is your responsibility to work directly with your health care provider before, during and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval from your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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