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Personalised Nutrition Plan Form

Eating Healthy is a way of life.

Healthy-food-Lunch-box-with-vegetables-salmon-avocado-smoothie-with-avocado-and-salad-with

Name and Surname

Email address

Whatsapp Contact

Date

Current weight

Are you a smoker?

Are you allergic or intolerant to any foods or medication?

Do you drink alcohol regularly?

Are you pregnant?

Are you currently/ have been recently on any prescribed medication?

Do you have history of the following? * Required

High blood pressure

Angina/chest pain

Heart disease

Stroke

Diabetes

Osteoporosis

Arthritis

Cancer

Hepatitis/HIV

Seizures

Headaches

Depression

Shortness of breath

Dizziness

Nausea

Insomnia

Bowel or gastro issues

Have you recently experienced any of the following: * Required

Unexplained weight change

Change in appetite

Change in bowel / bladder movement

Change in your all over health/wellbeing

Lifestyle

Do you eat breakfast and what time ?

Do you eat lunch and what time ?

How often do you order takeaway food

Do you cook yourself or a family member cooks for you?

Is there any foods you do not like to eat?

Do you snack and what times?

At what time do you eat dinner?

How many times per week do you eat out?

What time do you wake up ?

How many hours do you sleep?

Do you take breaks during the day to eat your meals?

Have you been feeling lethargic lately?

Are you concerned about your current weight?

Are you unhappy with the quality of your sleep?

Do you experience any side effects from medication you take?

Do you have concerns about the state of your skin or hair?

Are your teeth or gums causing you any discomfort?

Do you regularly drink large amounts of soft drinks , fruit juices , tea or coffee?

How much water do you drink daily?

Have you been feeling low or under the weather emotionally lately ?

Do you spend most days being physically inactive?

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audrey@eatfitmalta.com

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