Title Mr Mrs Miss

First name

Surname

Date of birth

Building name/number

Street

Town

County

Postcode

Telephone

Email address

Occupation

Marital status Married Single Separated Divorced Living with partner

Height

Weight

No. of children

Main health Issue
to address
(max 20 words)

Tell us about your dietary habits

Do you take time to prepare your own meals? Yes No

How many times a week do you eat out?

How many times per week do you eat take-away food?

How many times per week do you eat packet/instant food?

How many times per week do you eat pre-prepared/ready meals?

Do you eat wholegrain bread, pasta, rice? Yes No

Do you use salt in your cooking? Yes No

Do you put salt on your food? Yes No

How many times per week do you eat chocolate/confectionary?

Do you drink more than 1 litre of water per day? Yes No

How many tins of food do you eat per week?

How many servings of vegetables do you eat daily?

How many portions of fruit do you eat on a daily basis?

What is your preferred alcoholic drink?

How many units of alcohol do you consume on average during the week (M-F)?

How many units of alcohol do you consume on average during the weekend?

Do you drink milk (if yes, state how many pints/week)

How many teas/coffees do you drink per day?

How many teaspoons of sugar do you have per day?

Upload your completed food diary

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