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Basic information
First name
Last name
Phone
Birthday
Day
Month
Year
Email
Emergency contact Name
Emergency contact phone number
Pronouns
Health background
Multi select conditions
POTS
Endometriosis
Fibromyalgia
ADHD
Autism
Chronic Pain
Perimenopause/Menopause
IBS/IBD
Anxiety/Depression
Diabetes
Other
What brought you here today? What's your main concern or goal?
Medications and dosages/ frequency.
Food and eating patterns
Food & Eating Patterns Typical Day Eating (include volume and drinks)
Foods avoided and why
Sensory food issues
Texture Sensitivities
Temperature Sensitivities
Smell Sensitivities
Sound Sensitivities
Visual Appearance Issues
Cooking situation
Love cooking
Cook When Necessary
Microwave Warrior
Takeaway Hero
Someone Else Cooks
Cooking is Overwhelming
Lifestyle and stress
Lifestyle & Stress
Zen Master
Manageable
Elevated stress
Constantly Overwhelmed
What's Calm?
Stress sources
Work
Family
Health
Finances
Relationships
Everything
Other
Physical Activity
Regular Exercise Routine
Occasional Movement
Daily Activities Only
Limited Due to Health
Sleep Quality
What's Sleep?
Restless/Interrupted
Okay Most Nights
Generally Good
Goals and expectations
What would success look like in 3-6 months
Previous Nutrition Attempts:
Healthcare team
GP Name
GP Contact Number
Last Consultation Date
Specialist details
GP communication consent
Yes
No
Communication
Personal consultation preferences
Phone
Teams (online video meeting)
Text
Other
Follow-up Frequency:
Initial Phase: Every 2 weeks
Maintenance Phase: Monthly
Long-term Management: Quarterly
As Needed/Flexible
Accessibility Needs Multi-select
Need Written Materials
Prefer Visual Explanations
Need Breaks During Consultation
Other
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