About You

Please declare all relevant medical details below and understand that failure to do so will exempt Ruth Harvey from any liability.

Name

First Name

Last Name

Date of birth

MM

DD

YYYY

Occupation

Relevant medical history

Family history of heart disease, diabetes, dementia, cancer or other chronic conditions

Are you currently on prescription medication?

Yes

No

If you take any over the counter medications regularly please provide details

Have you been hospitalized recently?

Yes

No

Do you smoke?

Yes

No

Do you think you are peri-menopausal?

Yes

No

If yes, please list your 5 most troublesome symptoms

If post-menopausal, age at last period:

Do you suffer from diarrhoea, constipation, bloat or wind? If so, please give details here.

Declaration

I give my consent for a dietetic consultation with Ruth Harvey RD. I declare that the information provided on this form is true and accurate at the time of signing and that my identity is that stated on this form. I give permission for Ruth Harvey to contact my GP in reference to my treatment if required. Please PRINT name

Date

MM

DD

YYYY

Usual daily food intake

Name

First Name

Last Name

Please use this space to detail your usual daily food intake in a 24 hours period including meals, snacks, time consumed and quantities of each item (can estimate in cups).

Beverages: please list your usual intake of all beverages across a week including water, tea, coffee, herbal teas, juice, cordial, squash, and smoothies as well as alcohol (if consumed).

If you take any nutritional or herbal supplements please list these here