Pre-consult Form

We would like to know a little about your medical and diet history before we see you so that we can prepare for the consultation. Please fill out the form below.

Patient Details

This is for invoicing purposes and information needed should you wish to claim back from your medical aid.

Full Name *

ID Number

Phone *

Email *

Confirm Email *

Address *

Address

City

State/Province

Zip/Postal

Country

Medical Aid

Kindly confirm your medical aid details for invoicing purposes.

Membership Number

Are you the main member? *

Yes

Main Members Name and Surname *

Main Members ID number *

Main Members Phone Number *

Main Members Email Address *

Confirm Main Members Email Address *

Main Members Address *

Main Members Address

City

State/Province

Zip/Postal

Country

Nutritional Assessment

Gender *

Age *

Current Weight (kg's) *

Height (cm) *

Occupation

Do you have Children?

Yes

How many children do you have? *

Are you Pregnant? *

Yes

Are you trying to fall pregnant?

Yes

How many weeks have you been pregnant for? *

What was your pre-pregnancy weight? *

Marital Status

When were you diagnosed with diabetes? *

Please select the treatment(s) that you are on. *

No treatment currently - only dietary management

Metformin / Glucophage

Insulin

OtherOther

What is your insulin regime? What insulin are you taking and how many units?

Surgical History *

Please confirm any surgery that you have had throughout your life.

Do you have any Food Allergies? If so, please specify *

Do you have any Recent / Relevant Blood Results / Lab Values? *

Yes

E.g. Cholesterol levels / HbA1c / GTT / Blood pressure reading etc...

If you have a copy of your most recent blood tests, please upload it here.

Required upload size: 16.78MB

Are you taking any Chronic Medication? If so, please specify.

Are you taking any Meal Supplements / Vitamin or Mineral Supplements? If so, please specify. *

Do you have any Physical Complaints / Unusual Symptoms? If so, please specify. *

Are there any foods not mentioned above that you avoid or foods that you do not like? *

How many glasses of water do you drink daily? *

Do you Consume Alcoholic Beverages? *

Yes

How many days per week do drink an alcoholic beverage? *

How many units of alcohol do you have per day? *

Please indicate by no. of units: 1 unit = 350ml beer / 120ml wine / 1 tot spirit

Do you smoke cigarettes? *

Yes

Occasionally (social smoker)

What are your Personal Interests / Lifestyle Activities?

Do you exercise regularly? If so, what do you do and how often? Is there something that you would like to do?

How would you rate your stress levels? *

'1' being stress-free and '10' being unmanageably high.

How would you rate the quality of your sleep? *

'1' being very bad and '10' is excellent (you get 7-9 hours of quality sleep every day).

Select your nutritional goal(s) *

What is your GOAL Weight? (kg) *

Upload your before photo here (optional)

Required upload size: 16.78MB

Choose a full length image of you facing the camera and one side view with clothing on that shows your transformation clearly. PLEASE NOTE that like all the other information gathered from this assessment, this will remain confidential and that this is just for your reference and for the dietitian to see your body type. NuChoice will ask for WRITTEN PERMISSION from you first if we wish to use these pictures to add to our success stories.

Checkboxes *

I agree to the user agreement terms.

If you are human, leave this field blank.

Pre-consult Nutritional Assessment

Patient Details

Nutritional Assessment