Nutrition Questionnaire - Rossell Fitness

Name*

First Last

Email*

This is required so that I can send you a copy of your answers to the following questions for your records.

Do you have a history of dieting? If YES please outline in as much detail as you can below, if NO, please state NA.*

Have you ever had a diagnosed eating disorder? (for example anorexia, bulimia, binge eating disorder)*

Yes
No
Prefer not to say

Do you have a history of disordered eating, if YES please out line in as much detail as you can below, if NO please state N/A.*

Disordered eating can look like: rigid rituals and routines surrounding food and exercise. Feelings of guilt and shame associated with eating. Preoccupation with food, weight and body image that negatively impacts quality of life. A feeling of loss of control around food, including compulsive eating habits.

Please list 5 of your favourite fun foods*

A fun food is something that you might eat out at a restaurant or at a party, but may not have in your every day nutrition. For example my top 5 include: ice cream, chocolate, peri peri fries, hot chocolate and apple crumble

Please describe your typical meal schedule and a typical breakfast, lunch and dinner*

For example B = 8am, L = 12.30pm Snack = 4pm D = 6.30pm

Please describe/list 5 of your favourite every day snacks*

These would be things that you might snack on more regularly, for example mine would be melon, watermelon, hummus and carrots, banana bread, protein bars

Please add anything else that you feel is relevant to your nutrition, past or present...*

I give my consent for Nicola of Rossell Fitness to contact me using the information that I have provided in this questionnaire*

I consent

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