Name *

First Name

Last Name

Which of the following diets are you interested in?

Please leave blank if you are unsure or would like further advice.

Mediterranean

Paleo

Keto

Low GI/GL

Low Histamine

Intermittent Fasting

Gluten Free

Dairy Free

Lactose Free

Weight Loss

Vegetarian

Vegan

Other

Are you experiencing any of the following?

Please select all that apply. If you tick any of the boxes, please speak to your GP. I am unable to work with you at the present time but please feel free to get back in touch once your symptoms have resolved.

Black, tarry stools

Blood in sputum, vomit, urine or stools

Blueness of the lips

Change in bowel habit

Change in skin (rash, colour, bruising) / skin mole or lesion (size, shape, colour, bleeding, itching, pain)

Chest pain

Convulsions

Delirium (hearing voices/hallucinations)

Difficulty swallowing

Excessive thirst

Frequent nosebleeds

Increased urination

Loss of appetite

loss of consciousness

Loss of vision

Neck stiffness with fever

Non-menstrual vaginal bleeding

Pain on passing urine

Pain which is persistent, severe or unexplained in any part of the body

Painless ulcers or fissures

Pallor (abnormal lightening or paleness of the skin and mucous membranes)

Persistent cough

Persistent vomiting and/or diarrhoea

Severe mood changes/depression

Shortness of breath

Suicidal thoughts

Swelling of face, lips, tongue or throat

Unexplained fever, swelling or lumps, weight loss or gain

Vaginal bleeding with pain in pregnancy or after missing one period

Vomit containing “coffee grounds” (coagulated blood, twisted bowel)

Declaration: *

I confirm that I have answered all questions truthfully and to the best of my knowledge. I understand that failure to disclose any relevant information may impact the advice and guidance provided during consultations.