Client Registration Form

Thank you for taking the time to fill out this registration form. Your health and wellbeing are influenced by so many factors so the more information you can give us the easier it is for us to help you. All information on this form is treated as confidential.

Please complete the following questions to provide us with an overview of you and your lifestyle.

Name

For under 18, name of parent/guardian

Date of Birth

Address

Email

Phone number

Preferred Contact Phone Email

Occupation

Doctor’s details (name, address and phone number)

What is your reason for this consultation?

What are your health goals or concerns?

Medical History

Please provide details of any relevant medical issues/ illness/ allergies medications

Have you accessed nutrition advice before and what was the outcome?

Who do you live with?

Who does the shopping?

Who does the cooking?

Do you follow any of the following special diet/nutritional program?

Low Carbohydrate

Vegetarian

Vegan

Lactose free

Low salt

No gluten

Diabetic

Low FODMAP

Other

Any further details

Do you take any nutritional supplements?

Thank you

How did you hear about Summit Nutrition?