Pre-consultation form | Nikky May Nutrition

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Nikky May Nutrition

Gut Health Nutritionist

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Pre-Consultation Information

First name (same name you booked with)

Last name

Email (same email you booked with)

Phone

Weight in KG

Height in CM

Gender *

Female

Male

Do you smoke? *

No

Yes

Are you pregnant? *

No

Yes

Date of Birth

What is your physical activity level?

Occupation

Reason for consultation (you may check as many as you like)

Gut Health

Healthy Eating Education

Food Intolerance

General Nutrition

Are there any specific concerns or goals you'd like to address?

Are there any known medical conditions?

Do you take any medications or supplements that may affect your gut health?

Dietary Preferences: (you may check as many as you like)

Vegetarian

Vegan

Gluten Free

Dairy Free

Low FODMAP

Other

Any known food allergies or intolerances?

Your Typical Stress Levels *

Low

Moderate

High

What are your average hours of sleep per night? *

6 hours or less

7-8 hours

9+ hours

Any additional concerns or comments you'd like to share?

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ABN: 97 117 418 870

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