Contact Your Name Your email Your contact phone number What gender do you identify as? —Please choose an option—MaleFemaleOther Your date of birth (year, month, date) e.g. 1990-01-27 Your address Your occupation Reason for Visit Your height in centimetres Your current weight in kilograms Weight history (any recent weight changes or major fluctuations?) In a few words, how would you rate your general health? What are your current health concerns/goals? Have you had any treatment for the above concerns? Medical History (please include condition and details) Family Medical History (please include condition and details) What current medicines and supplements do you take? (please include name, dose, start date and purpose) Do you follow any special diet or do you have diet restrictions or limitations? Do you experience cravings, and if so what type of food do you crave? Are you a smoker? —Please choose an option—yesnosocial How many alcoholic drinks, if any, do you have each week? How many times per week do you participate in exercise? What type of exercise is it and what is the usual time duration? How many hours do you usually sleep each night? Do you have any known allergies (foods, medications, pollen etc.)? If so, please describe. How would you rate your stress levels out of 10? (1 = minimal stress and 10 = extremely high stress) —Please choose an option—12345678910 What are your nutritional/eating habits that you are most pleased with? What have you found in the past has been successful for your wellness and healing? What do you feel is the most significant item you would like to change? By submitting this form I agree to the following: * I am over 18 years and have the ability to make my own decisions. If not, I have my guardian's/carer's consent * I have and will to the best of my knowledge supply correct and relevant information to this particular consultation * It is solely my decision to participate in any suggested treatment strategies and I will do so under the guidance of Mel Trebilcock of Melt Nutrition I accept all of the above terms: YesNo Δ