The foods we choose to consume to nourish our bodies, Are so important to our overall health and vitality.  IT has an impact on your life and the lives of others around you. 

This holistic assessment will help you find real solutions that your body needs. 

 

This questionnaire is detailed, and is designed as such, to help uncover as much as possible. 

It will take you approximately 20 minutes to complete.

 

 

How to fill out this questionnaire:

There are 2 sections to complete.  below is your overall health and lifestyle snapshot.  take your time and answer every question.  if for some reason something important relating to you is not asked, feel free to use the sections at the end to add any further comments!

You will also need to complete a food diary that captures a typical week for you.  PlEASE ENSURE YOU HAVE EMAILED THIS THROUGH ONCE COMPLETED TO BIANCA@LIFEELITE.COM.AU.

 

Why are there questions about my bodily functions??

How we feel, our general health condition and complaints, can be directly affected and influenced by our nutritional status.  Remember HEALTH is HOLISTIC.  It is important to ask (sometimes uncomfortable) questions, especially in relation to your digestive health, to assess how your body is processing, and assimilating different foods and nutrients.  Your body can tell us if there are any signs of excesses or deficiencies, and how that is affecting your health overall. It is also essential for me to know any medications including supplements, to avoid any interactions. 

The more information you can provide, the more I can uncover for you.   

 

Let’s get going……

Name
Do you currently take any medicines or supplements?
Please list any medicines including pharmaceuticals, vitamins, supplements, herbal medicines etc. PLEASE SPECIFY THE BRAND, AND DOSAGE.
If none, please write "NONE"
E.g. Iron, Vitamin D.
Please select from the following:
Please select from the below:
Select which best describes your fruit intake:
Select which best describes your vegetable intake:
please select which best describes your fish intake.
Please select from the below:
Select from the list below:
This includes foods such as biscuits, cakes, confectionary, lollies etc.
Select which best describes your consumption:
Select which best describes your bread consumption. White, whole-grains, sourdough, seeded, gluten-free etc.
E.g. white, wholemeal, sprouted, gluten-free etc.
E.g. English breakfast, Earl Grey etc
This includes all sugars - white, brown, raw, agave, sweetener, xylitol, stevia etc.
E.g. Nausea, diarrhoea, bloating, cramps etc.
E.g. on the couch, in front of the T.V, table, car?
Do you suffer from any of the following:
click all that apply
Have you noticed anything unusual about/in your stool?
Select all that apply.
On a scale from 1-10. 1 = very poor. 10 = I jump out of bed!
On a scale of 1-10. 1 = no stress, 10 = extreme.
Please share anything else about your diet/health that may have been missed!
Tell me.