Step 2 – Complete Information Form – Naturally Energised Nutrition

Zoom & Skype Consultations Available– Simply fill out the Nutritional Consultation Form below.

Have you had blood tests done in the last 12 months?

Email a copy of the results over before your initial consultation.

This is very important to assist in gaining an understanding of your current baseline of health and will be addressed early within consultation.

Some private health funds still rebate for nutritional consultations. Please check with your individual fund.

Cancellation – Please, no less than 24 hours notice is undoubtedly appreciated.

Nutritional Consultation Form

FULL NAME

STREET ADDRESS

SUBURB/CITY/TOWN

POSTCODE

BEST CONTACT NUMBER

SKYPE or ZOOM ADDRESS

DOB

MEDICARE NUMBER

HEIGHT

CURRENT WEIGHT

GOAL WEIGHT

WAIST TO HIP RATIO (measured in clinic)

WHAT ARE YOUR MAIN REASONS FOR THIS CONSULTATION

IS THERE A PARTICULAR PROGRAM YOU WOULD LIKE TO USE TO ACHIEVE YOUR GOALS

OCCUPATION

TIME YOU WAKE

TIME YOU GO TO BED

DO YOU SLEEP ALL THE WAY THROUGH- if not, why not

HAVE YOUR EVER BEEN HOSPITALISED (if so, please give details and date)

ARE YOU TAKING PHARMACEUTICAL MEDICATION- INCLUDING HORMONES

ARE YOU TAKING ANY NATURAL SUPPLEMENTS

RATE YOUR STRESS LEVEL 1 TO 10 / Ten being most stressed

WHAT STRESSES YOU THE MOST

DO YOU HAVE ANY CHILDREN (if so, what are their ages, do they live with you)

DO YOU EXERCISE- if so, how many hours / what sort

DO YOU LIKE TO EXERCISE

ARE THERE ANY HEALTH CONDITIONS RUNNING IN YOUR FAMILY / ILLNESS' OF YOUR PARENTS OR GRANDPARENTS

DO YOU SMOKE OR HAVE YOU EVER, if so, when did you give up

HOW MUCH WATER DO YOU DRINK DAILY / TAP or FILTERED

DO YOU DRINK TEA OF COFFEE - how many per day

DO YOU HAVE MILK IN YOUR HOT BEVERAGES- if so, what type of milk

DO YOU USE ARTIFICIAL SWEETENERS

DO YOU DRINK ALCOHOL if so, what type / how often

DO YOU HAVE ALLERGIES- Please list

ARE THERE ANY FOODS YOU WILL NOT EAT. Your program will be personalised / Please give reason why you will not eat each food

A TYPICAL DAY

BREAKFAST- What do you eat- & time

LUNCH- What do you eat- & time

DINNER- What do you eat- & time

PREFERRED SNACKS- time/s you tend to snack

WHEN WAS THE LAST TIME YOU HAD BLOOD TESTS TAKEN. Please email through any test results you have had done in the last 12 months only

MEN STOP HERE PLEASE / If you have any further comments you would like to make, please do so here

WOMEN ONLY

ARE YOU IN MENOPAUSE

DATE OF YOUR LAST PERIOD

IS YOUR PERIOD PAINFUL OR HEAVY

IS YOUR PERIOD STILL REGULAR

ARE YOU TAKING THE CONTRACEPTIVE PILL

Please submit by clicking on the button below. You will not get notification of your email being submitted. However Kylie or the clinic will contact you within 48hrs to confirm a booking date & time. Thankyou- talk soon Submit

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Kylie McCarthy is registered with the Australian Traditional Medicine Society.
Provider number 27189.
Rebates are covered by Private Health Funds

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Medical- Legal Disclaminer

This site is not designed to and does not provide medical advice, professional diagnosis, treatment or services to you or to any other individual. Through this site and linkages to other sites, Naturally Energised Nutrition provides general information for educational purposes only. The information provided on this site or through linkages to other sites, is not a substitute for a professional consultation and you should not use the information in place of a visit, Skype consultation or the personalised advice of your health care provider. Naturally Energised Nutrition is not liable or responsible for any advise, course of treatment, diagnosis or any other information, services or product you obtain through this site.

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