Personal Information

Date of birth


Would you consider your current diet “healthy”?

WOMEN - Menstruating

Do you often skip periods?
Are you currently taking the birth control pill?

WOMEN - Perimenopausal / Menopausal

Are you noticing signs of menopausal transition?
Or gone through menopause already?
Are you on HRT?

Childhood and family history

Do you suffer from or regularly experience?

Select those that are frequent / common symptoms for you:


Your Habits

Please tick those statements that are most appropriate to you:

Basal Temperature and Pulse Self-Test

Record your temperature and pulse at the specified times, over three consecutive days. Take first temp and pulse for day on waking, before getting up or drinking or eating anything. With a digital or mercury thermometer, take your temperature (under the tongue with mouth closed). Please record your temperature in Celsius thank you. When taking pulse, make sure you’re in a rested state: count pulse at your inner wrist or neck over a 15 second period then multiply by 4.

Day 1

Date recorded

Day 2

Date recorded

Day 3

Date recorded

Your usual food intake

Give 2 examples of each meal that best represents your ‘usual’ eating

Additional Drinks

your average number of daily glasses/cups of each of the following:

Your tastes

Your Main Aims

What do you really want to get out of this

Please summarise your main reasons for making your appointment with me, what it is that you want to achieve and the main learnings that you want to take from me as your Nutrition Coach.