Patient Assessment Questionnaire

Before your first session, please fill the following comprehensive questionnaire so we can personalize your experience:

General Information

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Yes / No Questions

Do you have any health concerns? (Gastrointestinal, hormonal…)

Menstrual Cycle

Are you taking any medications?

Do you have any food allergies, sensitivities or intolerance?

Do you take any supplements, vitamins, minerals?

Do you drink alcohol?

Do you exercise?

Category Questions

Quality of Sleep

Water Intake

Usual Stress Level

Caffeine Intake (Cups per day)

Energy Scale (0–10)

0

Eating Patterns

Do you eat out unhealthily?

Do you feel you eat particularly slow or fast?

Do you cook?

How many times per week do you eat out?

Do you have sweets at home or at work?

Do you avoid eating certain foods or have a forbidden food list?

Do you allow yourself to eat certain foods that you are craving?

Do you eat when triggered or feeling sad or lonely?

Do you eat even if you are full?

Do you follow any food rules (i.e. I do not eat after 8:00pm)?

Who does the grocery shopping and food preparations?