Claire Hester MSc
Claire Hester MSc
Nutrition and mindset transformation coach
Health & Nutrition Questionnaire
Name
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First Name
Last Name
Email
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Age
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Date of birth
Phone Number
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Country
(###)
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Height
Weight
Waist measurement
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Primary reason for visit:
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Please list any part or current medical conditions that you have or are currently being treated for:
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Do you have any diagnosed food allergies or intolerances?
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Yes
No
If yes, please list:
Do you take any vitamin / mineral / herbal / sports supplements?
Yes
No
If yes, please list:
Do you smoke?
Yes
No
If yes, how much?
Do you drink?
Yes
No
If yes, how often and how much?
Please rate your daily stress level
1 - low stress
2
3
4
5
6
7
8
9
10 - high stress
How do you cope with stress in your daily life?
Do you sleep well?
How many times a day do you typically eat?
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Do you consume caffeinated beverages on a regular basis?
Yes
No
If yes, please list type of beverage and quantity.
Think: coffee, tea, fizzy drinks, energy drinks, etc.
How often do you eat take away foods per week?
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How often do you cook meals from scratch?
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Do you avoid any of the following foods?
Red meat
Poultry
Fish
Dairy
Vegetables
Fruits
Fried foods
Breads
Grains (pasta, rice)
Wheat
Foods you especially like:
Foods you especially dislike:
Have you recently gained or lost weight?
If yes, please explain if it was weight gain or loss, and what lead to the change in weight:
Have you ever had any concerns about your weight?
Yes
No
If yes, were the concerns for being:
overweight
underweight
Feel free to share any relevant comments here about your weight:
Have you ever tried to lose or gain weight in the past?
Yes
No
If yes, please explain:
Overall, how satisfied are you with the physical appearance of your body?
Very satisified
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Are you currently active?
Yes
No
If yes, what type of activity?
How many times per week?
How many minutes per session?
Please rate the average intensity of your workouts:
Light (walking slowly)
Moderate (walking briskly, light cycling, heavy cleaning)
Vigorous (running, hiking, fast cycling, team sports, weight lifting)
What nutrition related goals do you have?
What eating habits would you like to work on?
How important is it for you to make changes in your nutrition habits?
1 - unimportant
2
3
4
5
6
7
8
9
10 - very important
How did you hear about Claire Hester Nutrition?
Please enter today's date:
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Please check both boxes to indicate that you acknowledge:
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I have stated all known medical conditions, in confidence, and I take it upon myself to keep my nutrition consultant updated with any changes
I consent to this consultation and assessment and I choose to undertake any advice given of my own accord.
Payment link to invest in your chosen programme will be sent separately.
Thank you!