Intake Form

Data Privacy Statement

NUTRITION1ST LTD (www.nutritionfirst.life) Company Number 11647430 values your personal data and seeks to ensure it is stored and transmitted safely and securely.

Under the GDPR (General Data Protection Regulation) we control and / or process any personal information about you electronically using the lawful bases of contract. We are registered with the ICO under the Data Protection Register.

NUTRITION1ST LTD (www.nutritionfirst.life) uses the following third party systems:-

For form submitting data collection and storage

Jotfrom https://www.jotform.com/privacy/ 11 Pine St. Suite 1815, San Francisco, CA 94111 Data stored in EU under the preferences This is optional do not proceed with this form if you wish to get further information

For body composition analysis data collection, storage and mobile app usage

Inbody. https://uk.inbody.com/privacy-policy/ InBody Europe B.V. of Gyroscoopweg 122 1042AZ Amsterdam, Netherlands. Data stored in EU by default. This is Optional and measurments be taken without In body holding your data.

For email correspondence and client records

Google GSuite https://support.google.com/googlecloud/answer/6056650?hl=en Google London 1-13 St Giles High St, London WC2H 8AG Data stored in EU under preferences. In order for us to work and support you, we will need to store records.

Further detail will be presented with regards to pathology / Blood or DNA testing on a case by case basis.

All data can be delete upon request, please email info@nutritionfirst.life

I agree to NUTRITION1ST LTD (www.nutritionfirst.life) use of third partys to store and transmitte my private data. Otherwise please contact 02071933757 for alternative arrangements *

Yes I agree

Name

First Name Last Name

Email

example@example.com

Phone Number

Gender

Age

Occupation/Profession

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

GP Doctor - OPTIONAL

Name Address

Height and Weight - OPTIONAL

Height (m) Weight (Kg)

Briefly describe your reason for seeking nutritional support:

What are your 3 main health/fitness goals you wish to achieve?

On a scale of 1-10 how much do you want this change?

If we had a magic wand, what would be your outcome?

Have you suffered from any of the following conditions?

If you have selected any of the above and would like to elaborate please do so here:

Have you had any injuries, surgery, or hospitalisation in the past month? Please give any relevant details:

Are you currently under medical supervision for any conditions? If so, please give details:

Are you pregnant? (if applicable)

Yes No N/A

Please note down any medications you are regularly taking, both prescription and non-prescription, including dosage. This includes painkillers, herbal remedies, and homeopathic preparations:

Please note down any nutritional supplements you are currently taking (e.g.vitamins, protein powder etc.)

Please provide details of any illnesses or conditions that are present in your family or any family weight history:

How would you describe your diet? Select as many as you feel best apply to you

Please list any food intolerance or sensitivities, either diagnosed or suspected:

Please list any foods you avoid for health/religion/etc. reasons and if possible,outline why:

Are there any food types you particularly dislike and avoid in your diet?

What are your favorite foods and cuisines?

Are there any foods which would you find hard to give up?

On a scale of 1-10, how confident are you at preparing your own meals from scratch, using fresh ingredients, at home?

How often do you eat out? (times a week)

On a scale of 1 (unhealthy) - 10 (super healthy), how would you describe your diet?

How many people do you live with?

How many people do you cook for on an average daily basis?

Please select which of the following eating habits apply to you? Select as many needed

Which types of alcohol do you drink?

Beer Wine Spirits Others None

How many units of alcohol do you usually drink? 1 pint Beer /cider = 2 units. 1 glass of Wine = 2 units. 1 single Spirit = 1 unit

Per Week

How would you describe your drinking habits?

I do not drink Minimal social Small amount frequently Large amount infrequently Large amount frequently

How many cups of coffee do you drink per day?

How many cups of tea do you drink per day?

How many cups of juice or soft drinks do you drink per day? Or weekly?

How many glasses of water do you drink a day?

Do you smoke?

Yes No If yes how many? If you used to smoke when did you give up?

Do you consider yourself as?

Sedentary Low active Active Very active

On average, how many days per week do you exercise?

0 days 1-2 days 3-4 days 5-6 days Every day

Duration per session

Less than 30 mins 30-40 mins 45 mins or more

What the ways do you prefer exercise?

On a scale of 1 - 10, with 10 being the highest, how would you rate your current stress levels?

Are there any issues that are making you stressed at the moment? E.g. parenthood, moving to a new house, new job, family issues etc.

Select which. If any, of the following apply to you:

Difficulty getting to sleep Difficulty waking up in the morning Waking up often at night Finding it hard to relax

How many hours of sleep do you usually get?

What do you do to relax?

Do you have any hobby?

Is there anything else you would like to add or share?

I agree to the Disclamer *

Yes

Confidential Client Intake Form

Personal details

Health goals

Medical history

Family Medical history

Dietary Habits

Eating Habits

Lifestyle Factors

Physical Activity Level

DISCLAIMER