Dear new client, 

I would love to extend a warm and sincere welcome to you! I am so looking forward to working with you to reach your nutrition and health goals. Since this is your first consultation, I would like to take the time to get to know you better. The questions below include your medical history and questions regarding your relationship with food. The information provided assists me in providing an individual centred service to you. Please provide as much detail as you feel comfortable sharing. All information provided is confidential. None of the questions provided are compulsory. If you would like to omit any questions, please do so and continue onwards with the form. 

With gratitude 

Kirstin

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Medical Aid Details

Main member of medical aid

Next of kin

Medical history

Please note if you have a medical condition that impacts your nutritional requirements it is advisable to book an initial consultation with Kirstin (registered dietitian) for individualised nutrition education on your condition.

Do you experience any of the following conditions? If so please provide further detail.

Medication history

Obstetric history (female clients)

Psychosocial history

Your relationship with food and your body

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Diet history

Starting point

Measurements are often dreaded but vital for me to calculate your needs and for us to look back on and track your progress. 

Before you have anything to eat/drink please complete the following measurements. 

Lastly, the practice would find it incredibly beneficial if you could let us know where you heard about us? Referral, Social media etc.

Declaration and informed consent

I consent to providing the Personal Information required, to Kirstin Sylvester Dietitians, on the understanding that Kirstin Sylvester Dietitians is responsible to abide by the principles set out in POPIA, in the business’ POPIA Policy. 

I declare that all Personal Information being supplied by me to Kirstin Sylvester Dietitians is accurate, up to date, not misleading, and that it is complete in all material respects. 

I undertake to advise Kirstin Sylvester Dietitians immediately of any changes to my Personal Information, should any of the details change. 

By providing Kirstin Sylvester Dietitians with my Personal Information, I consent and give the Company permission to process and further process the Personal Information, as and when required, that I supply to the business, understanding the purposes for which the Personal Information is required and for which it will be used.

Thank you so much for taking the time to complete this detailed form! 

I look forward to partnering with you to optimise your health.

Thanks for submitting!

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