• Pre-Consultation Form (for Adults & Adolescents)

    for nutrition consultations with Amanda Benham, Accredited Practising Dietitian

  • Note: This form is for use by adults and adolescents. For consultations for babies and children under 12, please use the form located here: https://form.jotform.co/70049145626859

    The information in this form is required in order to provide you with a comprehensive nutrition / dietetic service. All your details and information supplied will be handled securely and treated confidentially. 

    For face-to-face consultations: If you have not returned this form prior to your consultation, you will need to complete it during your consultation time (or be asked a lot of questions), which will reduce the amount of time available for your consultation.  Consultations cannot proceed without the necessary background information, as you will not be able to be advised properly or comprehensively without the necessary information.

    For online (tele-health) and phone consultations: Please try to return this form at least 24 hours before your consultation time. If it has not been received prior to your consultation time, your consultation may need to be rescheduled.

  • Is this consultation to be in-person, or online (tele-health) or phone?*
  • Do you agree to being added to our email database so that you can receive an occasional newsletter? (I recommend you do this so you can be updated on any new advances in nutrition etc) Your email address will never be disclosed to a third party and you can unsubscribe at any time.*
  • What is your gender?*
  • Health History: Have you been diagnosed with or experienced any of the following conditions? (Check any that apply.)*
  • Please tick any symptoms that you're currently experiencing:*
  • Have any of your close blood relatives (parents, grandparents, siblings) experienced the following? Check any that apply.
  • Are you currently taking any prescription medication?*
  • Are you currently taking any vitamins, minerals, other supplements or over-the-counter medications?*
  • Do you smoke cigarettes?
  • Taking into account your usual occupation, your free time activities and any formal exercise, how would you describe your physical activity level in general?*
  • On average, how many hours per week do you spend outdoors between 10am and 4 pm, with bare arms and/or legs?
  • How many bowel movement do you typically have per day?
  • Females: Please answer the questions below as they affect your nutrient requirements.
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  • How would you describe your current eating pattern? (Check any that apply.)*

  • Foods Consumed: Please indicate how often you typically eat the following foods:
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  • Foods Consumed (continued) : Please indicate how often you typically eat the following foods:
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  • Foods Consumed (continued) : Please indicate how often you typically eat the following foods:
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  • At home, who does most of the food shopping?
  • At home, who does most of the cooking / food preparation?
  • How would you describe your usual appetite (desire to eat)?

  • Daily Eating Pattern:

    It will assist greatly if you can keep a record of everything you eat and drink for at least 3 days prior to your consultation. If you have a  smart phone, use the EasyDietDiary app to do this, then in Settings click "Send to dietitian" and email it to me prior to your consultation. (This will enable us to provide you with a complete nutrient breakdown of the foods consumed.)

    Alternatively, enter your typical eating pattern below.

  • Use the boxes below to outline your usual eating pattern. Please be as specific as you can. e.g. "2 slices of white toast with margarine and peanut butter and jam" is much more useful than just "toast".

    Giving a range of options and how often they are consumed per week is helpful too. e.g:

    6/7: 3 weet bix plus fullfat (brand) soymilk, black tea with 2 sugars

    1/7: 2 cinnamon donuts, soy latte 

     

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  • Cancellation Policy: Please note my cancellation policy is as follows:

    At least 48 hours prior to your first appointment, ensure you have either paid for your consultation (by Paypal to account amanda@humanherbivore.com), or provided your Visa or Mastercard details (either when booking in or below).  This confirms your appointment.

    Please try to give AT LEAST 48 hours' notice if you wish to cancel or reschedule your appointment.

    If you cancel/ reschedule your appointment with less than 24 hours' notice, your payment will be retained / you will be charged the full fee.

    If you cancel/ reschedule your appointment with 24-48 hours's notice, you will be charged 50% of the applicable fee.

    Please tick below to indicate that you have read and agree to the cancellation policy.

  • If you did not do this when booking in, please provide details of a valid Mastercard or Visa card (below) for payment of your appointment. (Please note that this is a secure site and this form will be encrypted before being sent to me securely.) 

  • Thank you for completing this form. The information you have provided will remain secure and confidential (unless disclosure required by law) and will assist in providing a comprehensive nutrition service for you.

    After clicking "Submit" please WAIT a few seconds to ensure you receive a message stating that your submission was successful.

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