Date *
Date
Name *
Name
Date of birth *
Date of birth
General anamneses:
Nutrition anamneses:
Breakfast
Appetite *
Snack
Appetite *
Lunch
Appetite *
Snack
Appetite *
Dinner
Appetite *
Snack
Appetite *
Tick the one which applies to you:
At a buffet you would normally prefer: *
Caffeine makes you feel: *
Except for sugary foods occasionally you prefer: *
For dinners you really like: *
After dinner you: *
The type of sweet snacks you prefer are: *
Eating heavy foods like meat, cheese and creamy sauces: *
Eating too much bread, fruit and crackers: *
Eating sweet snacks before bed-time:
Keep me up at night Give me a restless feeling in bed Keep me from falling a sleep
Daily you eat: *
Your attitude towards food is: *
When you skip a meal: *
Fatty foods for you are: *
If you would have a fruit salad for breakfast or lunch you would feel: *
What food typically would drain your energy: *
Your food proportions are: *
Potatoes for you: *
Read meat makes you feel: *
A salad for lunch would give you a: *
What do you think of salt? *
Snacks: *
Sour foods like pickles, vinegar, lemon: *
Sweet snacks like fruits, grains, bars: *
If you would have meats for breakfast like sausage, bacon and eggs, avocado you feel: *
Eating high fat foods make you feel: *
When you are nervous you would normally grab: *
My concentration is the best when I eat: *
You gain weight from: *
Your personality is more: *
Your mental and physical condition is better when you eat: *
Your preferred climate is: *
Your eyes in general are: *
The quality of your nails is: *
You react to insect bites: *
Are you ever constipated:
Do you ever have goose-bumps: *
Are you prepared to eat differently? *
What time do you normally wake up? *
What time do you normally wake up?
Do you wake up energized? *
What time do you go to bed? *
What time do you go to bed?
Do you ever wake up in the middle of the night? *
If so, what time is that normally?
If so, what time is that normally?
Do you play sports? *
Are you hungry after playing sports?
I acknowledge and agree to the following: *