PPT8 Pre-Screening and Consultation Form PPT10 Pre-Screening and Consultation Form PPT10 Pre-screening form for all participating clients Name(Required) First Last Are you a diabetic (Type 1 /2 / Pre)?(Required) Yes No Do you suffer from any know and diagnosed food allergies (peanut, glute, lactose)?(Required) Yes No If so, what are the food allergies? Do you suffer from any known/diagnosed digestive conditions (e.g. Chron’s, ulcerative colitis, IBS, reflux or disease similar).(Required) Yes No If so, what are the conditions Do you suffer any known conditions in which following a structured nutrition plan may cause further illness?(Required) Yes No Do you or have you ever suffered from kidney failure?(Required) Yes No Do you or have you ever had cancer?(Required) Yes No Do you or have you ever suffered from an eating disorder (anorexia nervosa, bulimia nervosa)?(Required) Yes No Do you ever suffer from unexplained diaherea or constipation?(Required) Yes No Have you ever undergone surgery for gastric bypass?(Required) Yes No Have you ever been recommended by a healthcare professional to see a dietician in regards to health concerns?(Required) Yes No Has a medical; practitioner ever told you that you suffer from a heart condition (heart disease or stroke)?(Required) Yes No Do you ever experience unexplained pain or discomfort in the chest during exercise?(Required) Yes No Do you ever feel faint, dizzy, lose balance unexplained?(Required) Yes No Have you suffered an asthma attack in which needs immediate medical attention?(Required) Yes No Do you suffer from any other know medical conditions?(Required) Yes No NEXT STEPSYES TO ANY OF THE ABOVE – If you answered yes to any of the above, a referral to an allied health professional including a dietician or GP is required prior to undergoing nutrition advice NO TO ANY OF THE ABOVE – If you answered no to all of the questions and you have no other concerns for your health, you may proceed to nutrition guidance.Are you currently seeing a physiotherapist or health care practitioner for any injuries, aches and pains?(Required) Yes No If yes, please list the reason Are you seeing a psychologist for any mental health related issues?(Required) Yes No Are you seeing a doctor for any health conditions or concerns?(Required) Yes No GOAL SETTINGPlease take a moment to consider the following:What is the primary goal you hope to achieve in our 8 Week Challenge?(Required)Why do you want this? What motivates you to achieve this goal?(Required)TRAINING INFORMATIONWhat's the plan for training? How many days per week do you have to exercise(Required) 2 3 4 5 6+ Anything else you think we should know prior to writing your program?For example; training outside, limited space, time for training, etcNUTRITIONAL INFORMATIONHow many meals do you eat on average per day?(Required) 3 4 5 6 Think of meals as main meals and planned snacks only. Do you eat very similar meals each day or are they more varied/ erratic:(Required) Do you have any major food likes or dislikes?(Required)Please list them here. What are your top 5 favourite healthy protein-rich foods?(Required) What are your top 5 favourite healthy carbohydrate-rich foods?(Required) What are your top 5 favourite healthy fat food sources?(Required) What are your top 5 favorite fruits and vegetables?(Required) How many meals do you EAT OUT, each week, on average? This is basically ANYTHING that hasn't been prepared at home(Required) 0 1-2 3 SUPPORTIn very simple, practical terms, what is it that you need to do to achieve your goals? i.e. what can we do for you?(Required)Do you own a set of digital bathroom scales?(Required) Yes No Do you own a set of digital kitchen scales?(Required) Yes No