pre-consultation Questionnaire Please complete the form as much as possible. 1Personal Information2Consultation3Medical Information4Lifestyle and Exercise5Dietary Habits6Consent Name* First Last Phone*Email* AgeDate of Birth* DD slash MM slash YYYY Gender Male Female Occupation Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What are the main reasons you would like to consult with a dietitian?Is this your first time seeing a dietitian? If no, what was the reason previously?What are your food and nutrition goals?What are your overall lifestyle and wellbeing goals?What are your expectations for the consultation?What are the biggest challenges preventing you from reaching your nutrition goals?If you could change 3 things about your health and nutrition habits, what would they be? Please list any current medical conditions and major surgeries:Do you have family history of the following: Diabetes High cholesterol High blood pressure Cancer Other (Please Specify) Other What medication are you currently taking?Do you take any vitamin, mineral or herbal supplements? Yes No If yes, please list supplements below, along with the dosage, frequency and reason.Do you have any food allergies or food intolerances? Yes No If yes please explain: What is your current height?What is your current weight?What was your heaviest adult weight and at what age? What was your lowest adult weight and at what age? How has your weight changed over the years?Are you happy with your weight? Yes No Why?At what weight are you comfortable? How would you rate your diet? Excellent Good Fair Poor Has your appetite changed within the past few months? Yes No Please explainHave you ever been on a diet? Yes No What diets have you tried?Are you currently following a special diet? Yes No What diet are you on?Do you exclude any foods for health reasons?Who usually does the grocery shopping? Who usually prepares your meals? Where do you eat your meals? With whom do you eat your meals? What is a normal meal pattern for you? (Tick all that apply) Breakfast Mid‐morning snack Lunch Mid‐afternoon snack Dinner Evening snack Do you frequently skip meals? Yes No Which meal(s)? What time do you usually eat:Breakfast Lunch Dinner Snacks Tick how often you snack a.m. snack p.m. snack evening snack snack between all meals grazing on food throughout the day Please list 3 options of foods you would usually eat for the following meals:BreakfastWeek day 1Week day 2WeekendLunchWeek day 1Week day 2WeekendDinnerWeek Day 1Week Day 2WeekendSnackWeek Day 1Week Day 2WeekendWhat are you favourite foods?What foods do you dislike?What foods do you crave?How often do you eat fast food or go to a restaurant? 0‐1 times/month 2‐3 times/month 1‐2 times/week 3‐4 times/week 5+ times/week List the restaurants you usually eat at when dining outPlease indicate the beverages you drink and amount - choose one option ( either daily, weekly or monthly)Coffee Regular Latte Decaf Daily Amount Weekly Amount Monthly Amount WaterDaily Amount Tea type Daily Amount Weekly Amount Monthly Amount Juice type Daily Amount Weekly Amount Monthly Amount Smoothie type Daily Amount Weekly Amount Monthly Amount Cold Drink Regular Diet Daily Amount Weekly Amount Monthly Amount Sports DrinksDaily Amount Weekly Amount Monthly Amount Energy DrinksDaily Amount Weekly Amount Monthly Amount Milk Whole 2% Skim Daily Amount Weekly Amount Monthly Amount Milk Alternative (Type) Daily Amount Weekly Amount Monthly Amount Alcohol Wine Beer Liquor Daily Amount Weekly Amount Monthly Amount Other: Daily Amount Weekly Amount Monthly Amount Food frequency: Please indicate how often you eat the followingRed Meat Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Pork Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Lamb Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Liver Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Poultry Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Deli Meat (ham, salami etc.) Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Fish Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Legumes (lentils, chickpeas, beans etc.) Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Crackers Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Confectionery (pastries, cakes, muffins, biscuits etc.) Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Crisps Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Wholegrain (brown rice, quinoa, oatmeal, bulgar, wholewheat flour etc.) Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Fresh / raw vegetables Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Cooked vegetables Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Fresh / frozen fruit Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Canned fruit and vegetables Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Margarine Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Butter Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Milk Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Yoghurt Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Cheese Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Fried Foods Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Frozen Meals Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day Home Cooked Meals Never 2-3 times / month 1 time / week 2-3 times / week 1 times / day 2-3 times / day What triggers you to eat? Tick all that apply Availability of food Loneliness Habit Lack of appetite awareness External cues Stress Social situations Sadness Depression Boredom Hunger Self-reward Comfort PMS Anxiety Other Do you have problems with any of the following? Tick all that apply Nausea Vomiting Chewing / swallowing Heartburn Diarrhea Consipation Gas Appetite Feeling weak or faint Eating Style: Based on how you eat on a regular basis, please tick all that apply: Fast eater Erratic eater Emotional eater Late night eater Time constraints Eat because I have to Negative relationship with food Travel frequently Dislike healthy food Struggle with eating issues Love to eat Eat too much Confused about food and nutrition Do not plan meals Frequently eat fast food Rely on convenience items Poor snack choices Family members have different food preferences On a scale of 1 to 10 (1 = not at all confident and 10 = extremely confident)Rate yourself on your ability to make positive changes to your eating and exercise habits? 1 2 3 4 5 6 7 8 9 10 I hereby enter into the following agreement with Tracy Judd hereafter referred to as T Judd. Consent for Nutritional Counselling I hereby request and consent to T Judd providing Nutrition Counselling to myself or the client for which I am legally responsible. I understand that the consult will provide information and guidance about my diet, nutrition, and lifestyle. I understand that T Judd is a Registered Dietitian and does not dispense medical advice but will treat a diagnosed medical condition through medical nutrition therapy. Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessments are intended as a guide to enhance my nutritional health. T Judd will provide nutritional support and nutrition education that relates to existing medical conditions, prevention of chronic diseases, improved athletic performance and or for general healthy eating. Confidentiality Medical records and personal information and history divulged in the session to T Judd will be kept confidential, unless I consent to sharing my medical information. Consent for Telehealth / Web-Based Counselling Further, when I would like nutritional advice provided through telehealth or web-supported platforms (including but not limited to Zoom, Microsoft teams, Skype or Telephonic) I understand that these platforms will be used to provide healthcare services to me, and that the usual consent processes are followed. I understand that the consultation will be done via video/internet conferencing technology and I agree to this. Practicalities: The telehealth or web-supported consultation is done through a two-way video whereby T Judd can see my image on the screen and hear my voice. I may ask questions and seek explanation from T Judd regarding the methods and processes of telehealth and I may at any time ask that the telehealth consultation be stopped. I also acknowledge that if I request for the session to be stopped that it might not be in my best interest and I therefore release T Judd from being legally liable for this. Any paperwork exchanged will be provided through electronic means. I understand that telehealth may have limitations, such as data- and internet failures (e.g. dropped calls or bad reception). The data being used during the online sessions will be my responsibility and at my cost. I understand that all available information and all vital information regarding my medical conditions, diet, nutrition, and lifestyle need to be disclosed to T Judd, I acknowledge and accept the risks of non-disclosure. I understand and consent to the telehealth consultation being recorded. I understand that scheduling a telehealth consultation implies consent. I voluntarily consent to this and I understand the implications thereof.Consent* I agree to the consent form above.
