Nutrition Consultation – Strength Beyond The Surface

Thank you for contacting us for a Nutrition consultation. Please complete this in depth questionnaire at your earliest convenience. It may be useful to take a look at all the questions and have a think about them before you sit down to complete it as the more information you are able to give me, the more tailored your plan will be.

Please fill them out in as much detail as possible so I can have all the tools I need in order to create your plan for you, please feel free to ask me any questions you may have over the next few days as I’ll be happy to answer them. Please understand that I am unable to give you a prescriptive meal plan, but I can help you understand how to create your own meal plan and give you guidance on how you can achieve your goals.

I am automatically notified when you have completed your form and I will aim to confirm receipt of receiving it within 24hrs of you submitting. Please contact me if you don’t hear from me in this time frame.

Name *

First

Last

Email *

Phone

If you would like any contact via WhatsApp, please add your mobile number here

Age *

Occupation *

Height (cm) *

Weight (kg) *

Please weigh yourself in the morning, before you eat or drink anything.

What are your health and nutrition goals? *

Please be as descriptive as possible. For example, if you want to lose weight, please tell me how much you would like to lose and when you would like to lose it by. Don't worry if you don't know if it's realistic as this is something I can then advise you on. We can work together to make sure they are achievable.

Do you have any idea how many calories you currently eat per day? *

(It doesn't matter if you have no idea!)

Do you track your food or have you ever tracked your food? *

Yes - I'm currently tracking
Yes - I have tracked in the past, but am not currently tracking
No - I have never tracked my food

By tracking, I mean entering the food and drink you consume into an app like My Fitness Pal.

Are you interested in tracking your food? *

Yes - I would like to know more
No - I would rather not track my food
I'm indifferent

If you click yes, it doesn't mean you will have to track your food. It just means I will give you more information about this. If you are not interested in tracking every day, I won't bore you with all the details!

Would you be willing to keep a food diary for a week? *

There is no right or wrong answer here. Keeping a food diary is a great way to understand what you are eating, especially if you don't want to track everyday.

Have you followed a nutrition plan before? What methods have you previously tried? What methods sis you find successful? If you no longer do them, why did you stop? *

For example - I have tried Slimming World in the past. I lost 5kg but wasn't able to keep it off. I found the diet restrictive so I wasn't able to keep it up. Please also let me know what has worked well for you in the past.

Please describe what you think is a 'bad' day of eating... *

What causes you to have a 'bad' day of eating? *

How do you feel after a 'good' day of eating? *

Please describe what you consider a 'good' day of eating *

Do you have any allergies, intolerances or dietary requirements? *

For example, vegan, vegetarian, gluten intolerant, nut allergy etc

What does a typical breakfast for you look like? *

Please give as much information as possible. For example rather than saying eggs on toast, please say 2 eggs fried in oil, 2 pieces of brown toast with butter. Please also include drinks - coffee with milk/small glass of orange juice etc.

How much time do you typically have to prepare your breakfast? *

For example - I am usually rushing around getting the children ready so don't have much time to make and eat myself.

What does a typical lunch for you look like? *

Please give as much information as possible. For example rather than saying a ham sandwich and a packet of crisps, please say Tesco pre made ham sandwich and a packet of quavers. Please also include drinks.

How much time do you typically have to prepare your lunch? *

For example - I am not very organised and don't prepare my lunch. So I usually just get a meal deal from Tesco. I do have time to prepare the night before, I just choose not to.

What does a typical dinner for you look like? *

Please give as much information as possible. For example rather than saying a pizza, please say a Lidl Sourdough chargrilled vegetable pizza. Please include any drinks.

How much time do you typically have to prepare your dinner? *

For example - I cook for the family and usually have about an hour from getting home to getting it on the table.

Please tell me what you usually snack on and how much *

For example: I usually snack on some fruit like a banana mid morning and a chocolate bar mid afternoon

Please tell me about your hunger and energy levels throughout a typical day *

For example - I am usually hungry about 2 hours after breakfast. I have an energy slump around 3pm. I am usually starving by 5pm and need a snack at 8pm.

What are your loves and can't live withouts when it comes to food? *

This can be sweet and/or savoury.

Do you currently drink alcohol? *

How much water do you typically drink per day? *

Do you take any vitamins or supplements? *

If yes please add details - eg; multivitamins and protein powder daily

What barriers do you feel may potentially stop you from achieving your goals? *

For example - I have to cook for the family which includes 2 children. They don't always want the healthier option so this could affect my choices.

What are you expecting from me? *

What are your current exercise levels? *

I spend most of the day sitting (desk job) and I do not do at least 30 minutes per day of intentional exercise. Activities of daily living only, such as shopping, cleaning, watering plants, taking out the bins, walking the dog, mowing the lawn and gardening. No moderate or vigorous activities.
I spend most of the day sitting (desk job) and I do light exercise that is equal to walking for 30 minutes 3 times a week. More intense exercise can be performed for less time to achieve the same goal. For example, 15-20 minutes of vigorous activity, such as aerobics, skiing or jogging on a daily basis would put you in this category.
I spend a good part of the day on my feet (e.g. teacher, salesman) and I do light exercise that is equal to walking for 30 minutes 3 times a week. More intense exercise can be performed for less time to achieve the same goal. For example, 15-20 minutes of vigorous activity, such as aerobics, skiing or jogging on a daily basis would put you in this category.
I spend a good part of the day doing some physical activity (e.g. postman) and I do moderate exercise that is equal to walking for 1 hour and 45 minutes. More intense exercise can be performed for less time. For example, jogging for 50 minutes per day.
I spend most of the day doing heavy physical activity (e.g. labourer) and I do hard exercise/sport daily.

If you don't feel you fit into any of these, please pick the closest and give more details in the next question.

Any other notes on your current exercise levels

Anything that may help me understand how many calories you typically burn each day. The more information you give, the better.

Are you looking to increase your activity levels in the next few weeks *

Yes
No
Not sure

How committed are you to achieving your goal?

Selected Value: 0

1=not very committed 5=reasonably committed, but it's not everything to me 10=I want this so badly so I am fully committed

Is there anything else you feel that would be helpful for me to know?

Disclaimer *

I understand the below

By using our Services and this website, the User agrees to the following: Our Services and its Content are not intended to replace a one-on-one relationship with a qualified health care professional or as a substitute for consultations with qualified health professionals who are familiar with your individual medical history or health needs. We are not providing health care, medical or nutrition therapy services or attempting to diagnose, treat, prevent or cure in any manner whatsoever any physical ailment, or any mental or emotional issue, disease or condition. We are not giving medical or psychological advice whatsoever. Do not disregard professional medical advice or delay seeking professional advice because of information you have read, listened, or watched on our Services or received from us. Do not stop taking any medications without speaking to your physician, nurse practitioner, physician assistant, mental health provider or other health care professional. If you have or suspect that you have a medical or mental health issue, contact your own health care provider promptly. I fully understand the qualification that Rachel Howard holds, and understand that the advice given is hypothetical and not given from a medical professional.

Name