Registration Finalisation old

Please complete all sections of this form – this information is required to provide you with an appropriate meal plan.
Name*
Street Address*
City/Town*
State*
Post Code*
Email Address*
Date Of Birth* * DD/MM/YY
Phone*
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*
Diabetes*
HbA1c*
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?*