Book Telephone Consultation FOOD DIARY - Step 1 of 6Do you prefer to upload or complete online your food diary? *Upload Comprehensive Complete Basic OnlineUPLOAD: Food Diary *Notes for completing food diary *I confirm I have read the diary completion notesThis diary should include record of all food consumed over a three-day period. Do not cherry pick the days as this will not give an accurate representation of your diet. You should record all supplements, food and drink, and give an idea of the volume of food consumed. A good way to do this is to use household measurements such as • Handful – useful for things like fruits, vegetables, cereals, sweets • Tablespoon – things like seeds, sauces, • Teaspoon – condiments like honey, jam, ketchup etc. • Cup, ½ cup, ¼ cup – useful to measure pasta, rice, beans, lentils etc. Type or brand of some foods are also important, some examples are listed below: • Specify with bread the type, e.g. brown, white, wholemeal, seeded • Milk type e.g. whole, skimmed, semi skimmed, soya (sweetened or unsweetened) • Specify if juices or smoothies are home-made or shop-bought With supplements: • You will be able to fill out the brand and dosage of your supplements on the online form, however writing them here may also be helpful as you can specify what times of day you take your supplements which is important information. Food Diary - Day 1 *Food Diary - Day 2 *Food Diary - Day 3 *NextTitle *MissMrsMrName *FirstLastEmail *EmailConfirm EmailAddress *Address Line 1CityState / Province / RegionPostal CodePhone *Occupation *PreviousNextDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height *Please insert data as cmWeight *Please insert data as kgHow often do you exercise each week *Light (1-3 days)Moderate (4-5 days)Heavy (6-7 days)Type of Exercise (Tick all that apply) *WalkingAerobicsYogaPilatesCycling (for transport)Resistance Training (light)SwimmingCompetitive Team SportMartial ArtsCycling (for sport)RunningResistance Training (heavy)PreviousNextDo you have any diagnosed health conditions? *YesNoExample: Depression, Diabetes, Cardiovascular disease, Autoimmune Disease, Eating DisorderWhen was it diagnosed? *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Details of condition(s) *Do you have any health complaints NOT diagnosed by a doctor? *YesNoExample: Bloating, Fatigue, Headaches or CravingsWhen did they start? *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Details of complaint(s) *Do you have any history of chronic illness in your family? *YesNoExample: Diabetes, Cardiovascular disease, Autoimmune disease, HypertensionDetails of family illness *Include the type of illness and the persons relationship to youHave you had any major operations *YesNoExample: Appendectomy, Tonsillectomy, Gastric Bypass, Caesarean SectionDetails of operations *Include type of operation, year of procedure and if any complicationsDo you take any medication? *YesNoDetails of medication *Include name and useDo you take any nutritional supplements? *YesNoExample: Multi Vitamins, Fish Oils, Probiotics, etcDetails of supplements *Include name, brand, dose (refer to label) and how often takenPreviousNextWhen is your energy at its best? *MorningEarly AfternoonLate AfternoonEveningNightYou can choose more than one optionHow easy do you fall asleep at night? *Extremely EasyModerately EasyNeither Easy or DifficultModerately DifficultExtremely DifficultYou can only select one optionDo you have any allergies? *YesNoSpecify Allergies *Example: Nut, Dairy, Coeliac, etcDo you have any dietary requirements? *YesNoTick all thay apply *PescatarianVegetarianVeganGluten FreePreviousNextWhat are your short term goals (1-3 months) *What are your long term goals *GDPR Consent *Permission grantedGDPR Consent (General Data Protection Regulation) In order to submit this form. We will require your permission: 1. To store your data digitally 2. Contact you by email 3. Contact you by telephone 4. Contact you by SMS You can request to view any data we store at any time or exercise the ‘right to be forgotten’, should you wish.Legal Disclaimer *I confirm I have read & accept the legal disclaimerBy using nourish & blossom, I legally agree to comply with this legal disclaimer. nourish & blossom is not able to diagnose or treat any medical conditions. Any advice offered is in good faith and is not intended to replace the advice of your GP or any other medical practitioner. Our services are intended for general use and are not designed to diagnose or treat or replace medical advice. Any information or suggestions provided are not intended as a substitute for medical advice or treatment from a GP or other doctor. Any person suffering from a medical condition or unexplained symptoms must consult their GP before embarking on a nutritional analysis from nourish & blossom. Furthermore, it is your duty to inform your GP and any complimentary medical practitioner of any treatment or remedies that you are taking or intend to take. nourish & blossom or any of its staff, members or nutritionists cannot be held responsible for any claims relating to any illness or ailments that are deemed to have possibly arisen from reading any material on this website or advice offered by telephone or face to face consultation. The information we provide on the website is for general use and we do not claim that it is suitable or indeed applicable to everyone.Terms of Telephone Consultation *I confirm I have read & accept the terms of this bookingThese Terms and conditions are deemed to have been accepted on the submission of the booking. The terms and fees are non negotiable.In line with consumer contract regulations: You have the right to cancel a service made at a distance which starts the moment you enter into the contract (submission of the telephone booking) and lasts 14 days. If you cancel within this period we will issue you a full refund. If you choose to schedule your telephone consultation before the expiry period or within the 14 day cancellation period you agree to waive your cancellation rights. Cancellation Policy after cooling off period (and waived rights) A minimum 24 hours notice is required to reschedule a booked and confirmed appointment. If less than 24 hours notice or if Phoebe calls and the client is unavailable at the time of the booked call, the missed call is chargeable. Once a consultation commences, no refunds will be available for non completion, for any reason whatsoever. Prior to commencement of a consultation, 7 working days notice is required to cancel the booking in order to receive a full refund. For cancellations of less than 7 working days a £20.00 administration fee will be due. Appointment Acceptance By placing your order, you are making an offer. The contract will only be formed if that order is accepted by nourish & blossom. We further reserve the right to decline any registration or booking without explanation. In the event your booking is declined, we will process a full refund of any payment received. General Terms & Conditions The Terms and conditions are deemed to have been accepted on the submission of the form. These agreed terms are non negotiable and are accepted on submission of the registration form. Please note if at any time the client is not able to conduct themselves in a composed manner, Phoebe will terminate the call immediately and the client will forfeit any fees paid. GDPR (General Data Protection Regulation) You can request to view any data we store at any time or exercise the ‘right to be forgotten’, should you wish, once your appointment with us has been completed. Copyright © 2018 All information supplied by Phoebe from nourish & blossom either verbally written or implied remains the property of Phoebe or nourish & blossom at all times. Written permission is required to reproduce, record, publish or advise verbally any details of any download PDF book, notes, advice offered or consultation transcript or summary in any format whatsoever. This includes but is not limited to any details published on any forums or similar boards. Any information supplied by Phoebe or nourish & blossom is Confidential. Any passing of any information to anyone is strictly forbidden and subject to International copyright laws. These Terms are governed by the law of England & Wales and are subject to the exclusive jurisdiction of the Courts of England & Wales We reserve the right to amend these terms and conditions without prior notice.PreviousEmailSubmit