Before your virtual assessment

Tell me about your routine, so your plan can fit your life.

This short pre-assessment helps me understand your usual meals, activity levels, height, weight and priorities before your nutrition assessment. Your information will be used to guide a practical, personalised weight and lifestyle plan and calorie goal discussion.

Personal details

Full name *

Email address *

Phone number

Date of birth

Measurements

Complete what you know. If you have access to scales, please provide your current weight and height as accurately as possible.

Weight

Height

Health and safety information

This information helps Dr Adeyemi decide whether this assessment is appropriate and prepare for your consultation. It is not a substitute for urgent medical care.

Relevant medical conditions

Current medicines and supplements

Allergies or intolerances

Are you pregnant, trying to conceive or breastfeeding?

History of an eating disorder or disordered eating

Have you had bariatric or weight-loss surgery?

Are you currently receiving treatment from another weight-management service?

Do you currently experience binge eating, self-induced vomiting, prolonged fasting or severe food restriction?

Is there anything about your physical or mental health that may affect your ability to make changes to your eating or activity?

Typical food intake

Describe a typical day of eating as honestly as you can. There are no wrong answers.

Breakfast

Mid-morning

Lunch

Afternoon

Dinner

Evening / snacks

Drinks (including tea, coffee, alcohol, soft drinks)

Weekend eating: what is different?

Portions, takeaways, eating out, cooking, oils and sauces

Activity level

Occupation / daily activity

Sedentary time

Exercise / structured activity

Walking / steps

Typical weekly activity

Activities enjoyed / disliked

Alcohol

Type and amount

Days per week

Typical weekend intake

Effect on eating / snacking

Goals and priorities

What would you most like to change?

What do you feel is getting in the way?

Anything else you would like Dr Adeyemi to know before the visit?

I confirm that the information I have provided is accurate to the best of my knowledge and I consent to Dr Adeyemi reviewing it to assess suitability and prepare for my consultation.

Your responses are sent securely and reviewed only by Dr Adeyemi before your appointment.