Lisa Fabry Qigong & Yoga Therapy
Client Information Form: Diet
Part 1: DIET INFORMATION
Name
Date
FOOD SENSITIVITIES
Please tick any of the following foods to which you are intolerant or which give you discomfort.
Use the blank space to enter any other foods which cause symptoms.
gluten
dairy products
onions
nuts
sugar
wheat (bread, pasta, etc)
garlic
chocolate
tomatoes
eggs
dried fruit
capsicum
soy
citrus
Please add any other foods which cause symptoms.
BEVERAGES
Please give details of how much you drink of the following each day.
Please enter the type eg green tea, decaf coffee, almond milk, wine etc.
Please give fluid quantity in cups or ml if you can, an estimate is fine.
Water
Coffee
Tea
Milk
Fruit or Vegetable Juice
Sports Drinks
Alcohol
Other
FOOD PREFERENCES
What time do you eat your first food of the day? Last food of the day?
What foods or cuisines do you love to eat, and would not like to give up?
What foods do you dislike or have an aversion to?
Do you have any food philosophies or practices eg vegan, keto, low FODMAP, religious practice?
Who do eat with? Who does most of the cooking in your household?
On a scale of 1-10, how confident are you at preparing your own home-cooked food, from scratch?
What is your weekly food budget, and how many people does this have to feed?
Please tick or highlight any of the following that apply to you.
skipping meals
eating on the go
grazing throughout the day
eating in a hurry
eating while distracted (phone, TV, computer)
eating out more than once a week
ordering takeaway food more than once a week
eating when not hungry
eating late at night
eating too much
eating too little
Do you have any concerns about your diet or eating habits? if so, please explain.
Send
Part 2: DIET DIARY
Please record a typical day's eating
Name
Date
On rising
Breakfast
Drinks or snacks
Lunch
Drinks or snacks
Dinner
Drinks or snacks
Before bed
Send
lisa@lisafabry.com
Get my free guide: What to Eat for Healthy Bones
Everything you need to know about nutrients for your bones and where to get them with a plant-based diet.
Name
Email
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