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- Full Name
- Email
- Birth Date
- Gender
- Weight
- Height
- Activity
- Pregnant
- Breastfeeding
Personal profile
Before we proceed, please complete the details below so we can make an accurate assessment of your dietary requirements based on your personal settings. Your details will be kept strictly confidential and will only be used for purposes of the analysis. An asterisk (*) indicates a mandatory field.
*Full Name:
*Email:
*Birth Date:
(Please note: dietary analysis is not available for children under 5 year old)
*Gender:
*Weight: kg
*Height: cm
*Activity:
*Pregnant:
*Breastfeeding:
DIET ANALYSIS AND ADVICE

Below is a daily food record chart.

Please enter the foods that you normally eat. The aim is to record what you normally eat on a day by day basis so pick a day that reflects this. Please keep in mind that the more accurate the answer, the more accurate result for yourself. This is confidential and no one else will see your results.

Most people eat habitually so recording one average; normal day of your life is beneficial in reflecting your overall eating pattern. However feel free to write ‘or’ this food….

Also include the methods of preparation (boiled, fried, baked, steamed, canned, frozen), condiments (tomato sauce/ketchup, butter, cream in coffee).

Do remember to record any other snacks that you may eat – you need to record everything you eat regularly. If you skip meals – write skip.

Breakfast
- Breakfast
Morning tea
- Morning tea
Lunch
- Lunch
Afternoon tea
- Afternoon tea
Do you suffer from ‘afternoon’ sugar cravings ?
- Suffer from Cravings
Dinner
- Dinner
Snacks: What time of day you eat them.
- Snacks
How many take away or restaurant meals per week? What are the names eg? Big Macs or Chinese restaurant etc
- Meals per week
My worst ‘danger/craving’ foods are?
1.
- Craving Food
2.
- Craving Food
3.
- Craving Food
Daily water intake: number of glasses per day
- Daily water intake
Daily Consumption of:
Tea
- Daily Consumption of Tea
Coffee
- Daily Consumption of Coffee
Milk added?
- Daily Consumption of Milk added?
Sugar
- Daily Consumption of Sugar
Diet sweeteners?
- Daily Consumption of Diet sweeteners?
Cordials
- Daily Consumption of Cordials
Soft drinks
- Daily Consumption of Soft drinks
Alcohol drinks
- Daily Consumption of Alcohol drinks
Energy drinks/ (iced) coffee etc
- Daily Consumption of Energy drinks
Lifestyle factors:
Hours of sleep per night?
- Hours of sleep per night
Do you smoke?:
Do you need to lose some weight?
- Need to lose some weight
If yes the amount of weight you would like to lose
- Amount of weight you would like to lose
My height
- Your Present Height
My present weight
- Your Present Weight
My stomach measurement is
- Your stomach measurement
My health symptoms in order of severity are: (1 being the highest concern).
E.g. High blood pressure, fatigue, weight gain…
1.
- HealthSymptoms
2.
- Health Symptoms
3.
- Health Symptoms
4.
- Health Symptoms
Any Other Comments
- Comments
Your diet will be personally analysed by Naturopath Philip Bridgeman or his personal assistant and their advice will be sent directly back to you.
You will receive a reply in the next 24 to 48 hours.
Thank you!