Diet & Lifestyle Questionnaire

Pure Health & Wellness Clinic — Bassendean, Perth WA

(08) 9378 2774 · info@purehealthandwellness.com.au

Your Details

First Name*

Last Name*

Date of Birth*

Gender

Email*

Phone

Occupation

Typical Daily Diet

Please provide details of an average day's diet (or what you had yesterday). Include beverages, snack foods, use of diet products, artificial sweeteners, type of cooking style/method, restaurant meals, and fast food.

Breakfast time

Breakfast — what did you have?

Morning tea time

Morning tea — what did you have?

Lunch time

Lunch — what did you have?

Afternoon tea time

Afternoon tea — what did you have?

Dinner time

Dinner — what did you have?

Supper time

Supper — what did you have?

Snacks or sweets (if not covered previously)

Eating out

Fluid Intake

Diet Overview

How many meals do you eat per day?

Do you skip breakfast?

Do you eat between meals?

Servings of vegetables per day

Servings of fruit per day

Servings of grains/breads per day

Servings of protein per day

Servings of dairy per day

Do you eat meat/fish?

How much water do you drink daily?

Caffeine intake (coffee/tea)

Alcohol consumption

Food intolerances or allergies

Food cravings? (e.g. sugar, salt, chocolate, bread)

Supplements you take

Sleep & Lifestyle

Hours of sleep per night

Trouble falling asleep?

Feel rested upon waking?

Do you feel sleepy after meals?

YesNo

Recreational screen time per day

Exercise, Stress & Lifestyle

Exercise frequency

What do you do for exercise?

Stress level (1–10)

Do you smoke or vape?

Please list the things that stress you

How do you deal with this stress?

What are your hobbies?

Current and past history of recreational drug use (optional)

Describe your energy throughout the day

When was your last visit to a doctor and what was the reason?

When was your last visit to a natural/alternative health care practitioner and what was the reason?

Digestion

Bowel movement frequency

Describe bowel movements

Digestive discomfort?

Mood & Mental Wellbeing

Describe your typical mood patterns

Additional Information

Additional comments

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