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Getting to know you

General information

Date of birth

Emergency contact information:

Would you like us to provide your GP with a summary of your consultation, if requested?
Yes
No

Medical information

Have you ever been diagnosed with diabetes or pre-diabetes?
Yes
No
Do you have any of the following problems? Select all that apply.

My goals

Metrics

If you are comfortable, please share the following measurements. 

Nutrition

Do you consume any of the following foods? Select all that apply.

How often do you consume the following drinks? If “never” please leave blank. 

Lifestyle and routines

How would you describe your level of activity? Please select one.
Very lightly active (e.g., reading, writing, at my desk)
Lightly active (e.g., folding clothes, vacuuming, grocery shopping)
Moderately active (e.g., walking)
Active (e.g., brisk walking, swimming, cycling, yoga, rowing, jogging etc.)
Extremely active (e.g., running, sprinting, hiking, aerobics, volleyball, dancing, etc.)
Maximum effort (e.g., Tabata, HIIT, marathons, strength training, powerlifting, bodyweight etc.)

Please state your level of agreement with the following statements. 

I usually wake up feeling rested in the morning.
Agree
Disagree
I usually wake up feeling tired in the morning.
Agree
Disagree
I take naps during the day.
Agree
Disagree
I sleep and wake up around the same time every day.
Agree
Disagree


Thank you for taking the time to fill out this form.

Your honesty and openness in completing this form will help in crafting a plan tailored to your needs and aspirations. Please feel completely at ease sharing general information about yourself, including body metrics, medical history, etc.

 

Your wellness goals, nutrition habits, lifestyle, and routines are vital pieces of the puzzle that will guide us toward your desired outcomes.

Rest assured, there is no room for judgment here; only support, understanding, and collaboration.

​

Together, we will navigate this journey, addressing any challenges and celebrating every success along the way. Well-being is our priority, and by working together transparently, we can achieve remarkable results. Thank you for entrusting me with your health and wellness journey.

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