Health Counselling Booking Form

Health and Nutrition Counselling

Health and nutrition counseling involves providing individuals with information, guidance, and support to help them make informed decisions about their dietary habits and overall well-being. It focuses on promoting healthy eating patterns, achieving and maintaining a healthy weight, managing chronic conditions, and addressing specific nutritional needs.

How often do you seek advice or counseling on health and nutrition?

Daily Weekly Monthly Rarely or never

How often do you seek advice or counseling on health and nutrition?

Daily Weekly Monthly Rarely or never

Which of the following statements best describes your attitude towards seeking professional guidance for health and nutrition?

I am proactive and seek professional guidance regularly I would consider seeking professional guidance if I had specific concerns or goals I prefer to manage my health and nutrition on my own without professional guidance I am not sure if professional guidance would be helpful for me

What is your primary source of nutrition information?

Healthcare provider Nutritionist Online sources Family/Friends

Which of the following factors influences your dietary choices the most?

Taste preferences Health benefits Convenience Cultural or social influences

How would you rate your current level of knowledge about nutrition?

Excellent Good Fair Poor

How many servings of fruits and vegetables do you typically consume per day?

Less than 2 servings 2-4 servings 5-7 servings More than 7 servings

How often do you engage in physical activity per week?

5 or more times 3-4 times 1-2 times Rarely or never

Do you have any specific dietary restrictions or preferences?

How often do you read nutrition labels before purchasing food products?

Always Often Occasionally Rarely or never

How often do you consume sugary beverages in a typical week?

Daily 3-4 times 1-2 times Rarely or never

How often do you seek advice or counseling on health and nutrition?

Daily Weekly Monthly Rarely or never

How often do you experience digestive discomfort after meals? (e.g., bloating, gas, indigestion)

Always Often Occasionally Rarely or never

Are you currently taking any prescription medications or supplements?

Yes No

How often do you eat out at restaurants or fast food establishments?

Daily Several times a week Once a week Rarely or never

How do you ensure you stay hydrated throughout the day?

Drinking water regularly Consuming beverages like tea or coffee Drinking sugary or caffeinated beverages I don’t pay much attention to hydration

What is your email address?

What is your phone number?

Please select which of our Health and Nutrition counsellors you would like to book a session with:

Enter PDF Link of reports for specific health conditions(optional):