HPN - Personalised Nutrition Questionnaire

The purpose of this questionnaire is to assist in the tailoring of a personalised nutrition programme to address your bio-unique needs and goals. This questionnaire is designed to gain an insight into your health history and current health challenges, with a view to restore optimal balance and improve your wellbeing, performance and healthspan. All information supplied will remain confidential and compliant with GDPR.

Section 1: Health Goals

A. Health Future (10-20 years)

Spending a moment to define our desired health future empowers us to establish targeted, healthy habits, which can significantly reduce the risk of serious health complaints and disease later in life. In turn, this enables us to enjoy a longer period of our lives in vibrant health.

A1.1. Current Health Future (What might your health be like in 10-20 years if no action is taken)?

A1.2. Desired Health Future (How would you like your health future to be in 10-20 years)?

B. Health Goals (12 months time)

Write your top 3 goals for the next 12 months.

B2.1. Health Goal #1

B2.2. Health Goal #2

B2.3. Health Goal #3

B2.4. How committed are you to modifying your diet and lifestyle (based on recommendations) in order to achieve your goals? (on a scale of 1 to 10, where 1 is not at all, and 10 is extremely)

B2.5. Please detail any barriers standing in the way of you making changes to achieve your goals

Section 2: Health Snapshot

A. Health History

A3.1. Please list all health challenges, including any diagnoses, operations, injuries and health concerns that you have had in your lifetime. Indicate the frequency, date of onset and how you manage each issue.

B. Family History

4.1. Please state any major health conditions or disease within your family

C. Current Symptoms - do you suffer from any of the following (select as many as required)

5.1. Gut & Immunity

5.2. Cardiometabolic and Body Composition

5.3. Energy and Hormones

5.4. Brain and Detoxification

D. Current Medication and Supplements

6.1. Medication. Please list all drug prescriptions and over-the-counter medications you are taking or have taken in the past on a regular basis (including antibiotics, anti-inflammatories, steroids, NSAIDs, antacids)

6.2. Supplements. Please list all supplements (vitamins, minerals, herbs) you are currently taking or have taken in the last 3 months e.g. multivitamin, protein powder/bars, energy/vitamin drinks, fish oil

E. Anthropometrics

7.1. Date of Birth

7.2. Height (cm)

7.3. Current Weight (kg)

7.4. Highest Adult Weight (kg)

7.5. Lowest Adult Weight (kg)

7.6. Muscle Mass (if known)

7.7. Body Fat % (if known)

7.8. Blood Pressure (if known)

7.9 First name

Section 3: Dietary Analytics

A. Food Preferences

A8.1. What are your favourite foods?

A8.2. What food do you crave?

A8.3. What foods do you dislike?

A8.4. What % of your meals are home cooked?

A8.5. What % of your meals are take-away or pre-prepared?

A8.6. What % of your meals are taken in restaurants?

B. Food Intolerances / Food Allergies

B8.1 Please list any diagnosed food allergies or known/suspected food intolerances

C. Food Diary - Please share 2-3 x examples of each of your meals across a typical day, and state the approximate time you consume them. Please share as much detail and examples as possible.

9.1. On Rising

9.2. Breakfast

9.3. Mid-morning

9.4. Lunch

9.5. Mid-afternoon

9.6. Dinner

9.7. Evening Snacks

9.8. Water intake / or other drinks not already mentioned

Section 4: Additional Information

10. Please provide any additional information which may be relevant to your health or nutritional requirements.