Dietary Analysis Initial Form – Isabel Dawkes Health

*Name

Date of Birth

Gender

Current weight or best estimation if unknown

Heightor best estimation if unknown

How often in a week do you exercise?Gym, classes, running, sports etc

None

1-3 times per week

4-6 times per week

7+ times a week

What type of exercise do you do?

What is your profession/job?If studying, state student & study topic

How would you describe your daily activity level?walking/moving time separate to exercise

Minimal walking time/sedentary job (desk based)

30-60 mins walking (activity) time per day

1-2 hours walking time per day

3-5 hours walking time per day

Over 5 hours walking time per day

Are you a competitive athlete?

Yes

If yes, what is your sport?Do you work with other fitness/nutrition professionals? Please give details

Have you ever suffered with disordered eating/an eating disorder?If yes, please give details. If no, leave blank.

Do you suffer with any of the following conditions?

PCOS (poly cystic ovarian syndrome)

Endometriosis

Hyperthyroid

Hypothyroid

Are you pregnant or lactating (breast feeding)? (Women only)

Neither

Pregnant

Lactating

If you currently suffer from, or have history, with any condition so far not mentioned, please give details below

What are you hoping to gain from your Dietary Analysis?

By signing this form I understand that all the information I am providing is correct to my knowledge, and that the dietary & lifestyle information I supply will form the foundation of my dietary analysis. I understand Isabel Dawkes Health is not responsible for providing medical advice or care and I take responsibility for seeking adequate professional advice where needed. I understand that dietary analysis is not diagnostic nor does it take place of medical advice, intervention or medication. Any changes made to my diet and lifestyle based on my dietary analysis are through my own choice.

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Date