Intake Form

Confidential Client Intake Form

Version Number: V1.01
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
Personal details

Step 1
Name

First NameLast Name
Email
example@example.com
Phone Number
Gender
Age
Occupation/Profession
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Doctor - OPTIONAL

NameAddress
Height and Weight

Height (m) Weight (Kg)
Health goals

Step 2
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?
Medical history

Step 3
Have you suffered from any of the following conditions? Select as approprieted.

Allergies/intoleranceAnxiety/depressionArthritisAsthma/breathing problemBowels problems (IBS, Crohn’s, etc)CancerDiabetes/HyperglycemiaEar, eyes, nose, throat conditionsEating DisorderEczema/ skin conditionBinge eatingHeart conditionsEpilepsyHypertensionHigh cholesterolOsteoporosisMenstrual/menopausal problemsStomach ulcerSleep problem (insomnia, sleep apnea, snore)Urinary tract conditionThyroid problemsAny type of anemiaAny other issue or health condition
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 6 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) and if breast feeding make a note in the box (other)

YesNoN/AOther
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.)
Family Medical history

Step 4
Please provide details of any illnesses or conditions that are present in your family or any family weight history:
Dietary Habits

Step 5
How would you describe your diet? Select as many as you feel best apply to you

Omnivorous (plant & meat)Lacto vegetarian (dairy)Lacto-ovo ( dairy & egg)Ovo vegetarian ( egg)VeganHigh plant (80% +)High carb/low fatHigh fat/low carbHigh raw (80 %)Salt restriction / DASHMacro countingCalories restrictionPaleo dietMediterranean dietFODMAP dietOther
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?
Eating Habits

Step 6
Please select which of the following eating habits apply to you? Select as many needed

Eat fast / chew littleEat slowly/chew a lotSkipping breakfastRegularly missing mealsEating on the goEating aloneOrdering takeawayEating homemade foodGrazing throughout the dayEating when not hungryEating in front of your laptop or TVEating a lot of food late at nightAdding sugar to drinksEating mindfulness
Lifestyle Factors

Step 7
Which types of alcohol do you drink? If applicable

BeerWineSpiritsOthersNone
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 drinkMinimal socialSmall amount frequentlyLarge amount infrequentlyLarge 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?

YesNoIf yes how many?If you used to smoke, when did you give up? give details in the box below.Other
Do you consider yourself as?

Sedentary (mainly siting)Low active ( exercise1-2 days a week)Active (exercise 2-3 day a week)Very active (exercise hard daily)
Physical Activity Level & lifestyle

Step 8
On average, how many days per week do you exercise?

0 days1-2 days3-4 days5-6 daysEvery day
Duration per session

Less than 30 mins30-40 mins45 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 sleepDifficulty waking up in the morningWaking up often at nightFinding it hard to relax
How many hours of sleep do you usually get?
What do you do to relax?
Do you have any hobby?
Food Diary - Please note down what type of food do you usually eat for: BREAKFAST, LUNCH, DINNER and SNACKS? (If you wish do a 3 days food diary in a separate sheet)
Is there anything else you would like to add or share?
DISCLAIMER

I understand that Elizete Reis-Bennett is working on behalf of ‘Nutrition1st Ltd’ and that nutritional consultancy is not a substitute for professional medical treatment. The nutritionist does not diagnose medical conditions, but may help, manage them through dietary recommendations. I also understand that the nutritionist may request some Biochemical medical tests or doctor's medical letter if necessary. I therefore understand that Nutrition First may refuse to continue the consultations to me (the patient name) if she deems it inappropriate due to a lack of medical treatment for a serious condition, or other reason. Likewise, the patient may also withdraw the consultations if they wish to do so. I understand that if I have an active eating disorder my nutritional consultations may not be able to proceed until I have written permission from my doctor or therapist. I accept the conditions of the disclaimer.
I agree to the Disclamer*

Yes
Should be Empty:

Confidential Client Intake Form

Personal details

Health goals

Medical history

Family Medical history

Dietary Habits

Eating Habits

Lifestyle Factors

Physical Activity Level & lifestyle

DISCLAIMER