Screening Questionnaire | Wave Nutrition Consulting

First name

Age

Last name

Phone

Email

Are you currently under the care of another health professional, for example Dietitian or other health specialist?

Explain briefly why you have rated your own health this way?

Other

Have you recently experienced any changes in your menstrual cycle? If so, please explain:

Do you believe that you are going through peri-menopause, menopause or post menopause? If so, please explain:

Out of all of the symptoms you selected, are any of these new or have they increased in severity recently (last 3 - 6 months)? Please explain:

Out of all your symptoms you selected, choose the top 2 that are causing the most concern?

Do you drink alcohol? If yes, how many days per week?

Do you smoke?

Are you currently following any particular diet? (e.g. keto, paleo, gluten free), and for how long?

Do you have any food allergies/intolerances? If yes, please list:

Please list all medication you are currently taking and for what reason? (Also include any HRT or bioidentical hormones that you have taken recently or in the past)

Please list all supplements you are taking and for what reason?

How often do you exercise per week and at what intensity? For example: 3 times per week – two 30 minute jogs and one 30 minute weights session).

Have you previously found it difficult to make lifestyle changes and maintain them? If so, what obstacles stopped you from achieving your goals?