Live the life your body wants
Your Name (required)
Your Age (required)
Sex (required) FemaleMale
Your Email (required)
Mobile # (required)
Height in cm (required)
Weight in kg (required)
How did you find Green Apple Nutrition ?
What do you want to achieve?
Lose weightGain weightLose body fatMaintain weightBuild muscle
Fitness Goals :
Improve general fitnessPhysique competition/ modellingOptimise athletic performanceMake weight for a competitionImprove strength
Health and Wellness Goals :
Feel betterHave more energy and vitalityImprove eating habitsManage weight and health around pregnancyResolve digestive issuesReduce stressRehabilitate
If you had to choose only one, which of these goals would be the most urgent and why?
Do you have any other goals?
When do you want to achieve this by?
Is there a reason for this deadline?
Please list your concerns about your health, eating habits or body image if applicable.
What have you tried before to change your eating habits, health, fitness or body image?
Have you made any changes recently?
Until now, has there been something that has blocked you or held you back from changing your habits?
Right now, how would you rate your overall eating/nutrition habits? 012345678910
Are you regularly active in sports, exercise, or other movement/activity?
How many hours would you be involved in doing sport or exercise on average per week? Fewer than 5 hours per week5-9 hours per week10-14 hours per week15-19 hours per week20 hours or more per week
What types of sports or other types of activities do you typically do? (Sports like swimming or going to the gym or activities like gardening, walking to school or moving around at work etc..)
Who do you live with? MyselfSpouse or partnerFlatmatesChild(ren)Pet(s)Other family
Who usually does the cooking and shopping?
Right now, how much do the people and things around you support your health, fitness and desire to change?
Your health and medical history
Do you or have you had any of the following?
Type 1 diabetesType 2 diabetesAnaemiaEating disorderIBS or stomach or intestinal problemsPolycystic ovaries (PCOS)High or low blood pressureCancer, cysts, tumourThyroid issuesBlood diseaseImmune disorderHormonal imbalanceAnxiety or depressionCoronary diseaseAllergies or eczema
Do you have any other medical conditions?
Are you currently taking any supplements or medications? If so, which ones?
Are you currently pregnant or breastfeeding?
Do you smoke regularly?
If you drink alcohol, how much and how often?
Do you drink coffee or other drinks that contain caffeine?
Do you have any food intolerances?
Do you follow any particular eating regime: paleo, vegetarian, low carb etc..?
How would you characterise your stress level on an average day? ("0" being no stress) 012345678910
On average, how many hours do you sleep at night?
4 or fewer hours5 hours6 hours7 hours8 hours9 hours10 or more hours
How do you normally cope with stress?
I do hereby state that I have, to the best of my knowledge and belief, given a correct and accurate medical history report. If there are any errors or omissions I will advise my nutritionist as soon as possible. If you have any serious health conditions which might be exacerbated by taking on a new exercise programme or eating routine, please acknowledge that any changes are not to be undertaken without prior approval from your doctor. If you choose to use the information your nutritionist provides without such prior approval, you agree to accept full responsibility for your decision.
Please tick the box to indicate that you have read the above statement
Get the latest posts direct to your mailbox from Rosanne.