Registration Finalisation

Please complete all sections of this form – this information is required to provide you with an appropriate meal plan.

Name: (required)
Address: (required)
City/Town: (required)
State: (required)
Post Code: (required)
Email: (required)
Date of Birth:
What specific issues would you like Alexander Dietetics to address, and what outcome would you like us to help you achieve?
Are you referred by a doctor?
What kind of doctor’s referral do you have?
Do you currently suffer from, or have you ever had, any of the following conditions:  
High Triglycerides
High Cholesterol
Blood Sugar Readings
High Blood Pressure
Heart Surgery
Kidney Disease
Liver Disease
Other (eg. Irritable Bowel Syndrome)
If Yes or Dont Know to any of the above please provide as much information as possible
(eg. recent cholesterol result, recent blood pressure reading)
Current weight in kg:
Height in cm:
Waist measurement in cm (approx. 3 – 4cm above the belly button):
Medications currently taken (please list as many details as possible):
What are the minimum and maximum amounts for each of the items below that you will consume in ONE DAY
Glasses of water: Min
Glasses of water: Max
Cups of coffee: Min
Cups of coffee: Max
Cups of tea: Min
Cups of tea: Max
Glasses of soft drink: Min
Glasses of soft drink: Max
Please specify type of soft drink (eg. Coke):
Glasses of fruit juice: Min
Glasses of fruit juice: Max
Pieces of fruit: Min
Pieces of fruit: Max
Alcoholic drinks:: Min
Alcoholic drinks:: Max
Please specify type and size of alcoholic
drink (including mixers) most regularly consumed.
(eg. Schooner light beer, small glass red wine, tall gin & tonic):
Is there any other information about your
medical history that may be relevant?

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