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The Health Dietary Reboot Questionnaire
Stiana Hubert
2025-02-01T08:48:27+00:00
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Please complete the brief questionnaire, as the information will enable me to provide you with a dietary plan specific to your needs.
Name
First
Middle
Last
Date of Birth
Day
Month
Year
Age
Gender
Female
Male
Address
Street Address
Address Line 2
City
County
Post Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
Home Phone
Mobile Phone
How would you rather be contacted?
Home Phone
Mobile Phone
Email
Your Weight
Your Height
Occupation
What work do you do?
How many hours do you work on average a week?
Do you work night-shifts?
Yes
No
Do you enjoy your work?
Yes
No
Do you have exposure to chemicals at work?
Yes
No
Health, Lifestyle and Exercise
Please state your key health goals and what areas of your health you would like to improve.
Do you smoke?
Yes
No
How many cigarettes do you smoke each day?
Do you drink alcohol?
Yes
No
How many days a week on average do you drink alcohol, how much do you drink each day and what is your preferred drink?
Do you exercise?
Yes
No
How many times each week?
On average how long do you exercise for?
What type of exercise do you do?
How would you describe your current lifestyle?
Stressed
Happy
Unhappy
Busy
Relaxed
Do you feel you can easily handle stress in your life?
Yes
No
What is the average number of hours you sleep each night?
6 or less
6 - 8
8 - 9
9 - 10
10+
Medical History
Allergies
Dairy
Soy
Wheat
Yeast
Gluten
Lactose
Artificial flavourings/colourings
Metal Jewellery
Plasters
Latex
Rubber
Dust Mites
Grass
Pollen
Fur
Food
Medicines
Do you suffer from any major/re-current illnesses (e.g. hepatitis, jaundice, diabetes, TB, glandular fever, asthma, herpes or shingles)? Please give details where appropriate.
Do you currently take any prescription medication?
Yes
No
Do you currently take any prescription medication, if so please list them below and please specify whether you experience any side effects.
Do you currently take any nutritional supplements? If so please list them in the table below and please state whether you experience any side effects.
Do you experience muscle cramps or spasms?
Yes
No
Do you have trouble thinking or concentrating?
Yes
No
Do you suffer any bloating and a sense of abdominal fullness?
Yes
No
Do you suffer any reflux?
Yes
No
How many times a day do you produce a stool?
Do you experience any pain when passing a stool?
Yes
No
Have you noticed any blood in your stool?
Yes
No
Does your stool(s) float?
Yes
No
Are you generally constipated, or straining during bowel movements?
Do you fluctuate between being constipated and having diarrhoea?
Yes
No
Do you suffer from haemorrhoids?
Yes
No
Do you experience any rectal itching or cramping?
Yes
No
Do you feel experience abdominal discomfort or nausea after eating fatty foods?
Yes
No
Have you had any weight change recently?
Yes
No
Do you suffer with eczema?
Yes
No
Do you suffer with psoriasis?
Yes
No
Do you experience urgency to urinate?
Yes
No
Do you experience excessive thirst?
Have you ever had Gestational Diabetes?
Yes
No
Hypothyroidism
Yes
No
PMT
Yes
No
Are you in Menopause?
Yes
No
Do you have Weight Gain?
Yes
No
Do you have Joint Pains?
Yes
No
Rate your levels 1 - 10 (1=low, 10=high)
Rate your energy levels
Please enter a number from
0
to
10
.
Rate your memory
Please enter a number from
0
to
10
.
Rate your concentration
Please enter a number from
0
to
10
.
Rate your general mood
Please enter a number from
0
to
10
.
Rate your general well-being
Please enter a number from
0
to
10
.
Nutrition
Have you ever seen a Nutritional Therapist?
Yes
No
Do you currently follow a specific diet, such as Low Fat, Paleo, Vegan, Wheat Free, Dairy Free, 5:2
Yes
No
Please specify which and how long you have been on eating in accordance with this?
Have you made any changes to your eating habits due to health?
Yes
No
Please specify
Do you struggle with your weight?
Yes
No
Which weight loss plans/programmes have you tried and were any effective?
How often do you weigh yourself?
How would you rate your appetite?
Please enter a number from
0
to
10
.
(1 = low/10 = high)
Do you enjoy food?
Yes
No
Do you avoid any particular foods?
Yes
No
Please specify and state the reason why
Do you have any specific cravings for foods?
Yes
No
Please state which foods
What are your favourite foods?
Who does the cooking at home?
Who does the food shopping?
Where do you buy the majority of your food?
How many times a week do you dine out?
What sort of food do you eat if you dine out?
What foods and drinks would be hardest to cut out?
How many cups of tea and coffee do you drink a day?
Do you add sugar to your drinks?
Yes
No
How many teaspoons?
How many glasses or volume of water do your drink each day?
Do you normally eat white bread, pasta and rice?
Yes
No
Do you normally eat brown bread, pasta and rice?
Yes
No
Do you eat/drink/use:
Candy/sweets
Yes
No
Refined sugar
Yes
No
Fizzy drinks
Yes
No
Fast-food restaurants
Yes
No
Distilled water
Yes
No
Fried foods
Yes
No
Filtered water
Yes
No
Deli meats
Yes
No
Margarine
Yes
No
Cordials
Yes
No
Artificial Sweeteners
Yes
No
Please provide any additional information that you feel may be useful to support your plan.
File Upload
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Please provide any blood test, test results or any other medical information that may be useful for your consultation.
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