Name
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First Name
Last Name
Country/City
Date of Birth
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MM
DD
YYYY
Email
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Phone Number
(###)
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Describe your primary health concern or nutrition goals you would like support with:
Until now, what has blocked you or held you back from working towards these goals? Have you tried anything in the past?
Do you currently take any medications? If so, please provide details.
Do you currently take any supplements? If so, please provide details.
How regular is your menstrual cycle? Have you had/do you currently have any issues, concerns, pain, etc?
Please provide a detailed description of your current exercise/training routine. Do you play a sport? Have you played in the past?
Do you live at home? Are you the primary food/grocery shopper?
For breakfast I usually have...
For a morning snack I usually have...
For lunch I usually have...
For afternoon snack I usually have...
For dinner I usually have...
After dinner I usually have...
Any other food or drinks? Please include any social habits (drinking, smoking, recreational drugs,etc)
What does your nutrition look like around your training? Do you eat before, during or after training/games? Please add in training/games times where appropriate.
Do you usually meal prep your food? E.g. Meal prep your lunches for work/uni
What is your height?
If you feel comfortable sharing, what is your current weight? (A range is fine as body weight fluctuates!)
How often do you use scales as a measure of progress? Is this something of importance to you?
How confident are you with your cooking skills and your general nutrition understandings?
Have you tracked macros/calories before? How did this make you feel?
Would you like your meal plan to include detailed calorie and macronutrient information? Additionally, do you prefer a structured daily eating plan or a more flexible guide where you can choose meals from a selection of recipes for the week? Please state your preferences.
Which service are you interested in?
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One Off Nutrition Consultation & Guide
One Off Game Day Plan
8 Week Youth Athlete Coaching Program
12 Week Coaching Program
Lastly, how did you find us?
Checkbox
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INFORMED CONSENT FOR NUTRITION CARE
Consent to Treatment and Treatment Disclaimers
I give consent to Angelene Alexandrakis, to provide nutrition counselling to myself or the client for which I am legally responsible. All consultations aim to provide personalised guidance and educational information related to my diet, nutrition, and lifestyle.
I understand that Sports Nutritionists are not qualified to provide medical advice, diagnoses, or treatment for medical conditions.
The role of an Accredited Nutritionist is to provide nutritional support and nutrition education to help manage symptoms related to medical conditions in the hopes of improving overall quality of life. The role of an Accredited Sports Nutritionist is to maximise performance through nutrition by providing practical strategies, guidelines and policies as well as support to athletes regarding the strategic timing of food and fluids.
Nutrition counselling is not a substitute for the diagnosis, treatment, or care of disease by a medical doctor. It is advised that the client discuss changes to diet and supplement intake with their primary health care physician.
To provide personalised and safe dietetic service, it is important that you inform your practitioner of:
• Any disease/condition from which you currently suffer
• If you are taking any prescribed or over-the-counter medications or supplements
• If you are pregnant, suspect you are pregnant, planning to become pregnant or are currently breastfeeding.
I understand that results are not guaranteed, and that nutrition is not a cure to medical conditions. In no way should a client discontinue or change the daily dose of any prescription medications without first consulting with their doctor.
The Nutritionist will answer questions to the best of her ability and will base suggestions on scientific evidence and relevant information provided.
The client expressly assumes the risks of nutrition coaching sessions, including the risks of trying new foods, and the risks associated with making lifestyle changes.
The client releases the Nutritionist from any and all liability damages causes of action, allegations, suits, sums of money, claims and demands, in law or equity, which the client ever had, now has or will have in the future against the Nutritionist, arising from the client’s past or future participation in the nutrition sessions, unless arisen from the gross negligence of the Nutritionist.
With this knowledge, I voluntarily consent to the treatment recommended to me by my practitioner. I intend for this consent to apply to all my present and future Nutrition care. I understand that I may retract my consent at any time during sessions.
Privacy and Confidentiality
Any information collected by the Nutritionist will be kept private and will not be discussed or shared with any third party unless compelled to by law (e.g. when there is imminent danger to the client or to others) or with the consent of the client (e.g. in the even that the Nutritionist must reach out to family physician). You may request information from your personal file at any time by contacting Angelene Alexandrakis directly.
All health records will be stored in secure online software. All meal plans will be prepared and stored in Canva.
Intellectual Property
Any informative resources, recipes or worksheets provided by the Nutritionist remain the intellectual property of Angelene Alexandrakis and are for personal use only. Materials are not to be reproduced or re-distributed without permission.
Payments and Refunds
Payments for all services will be automatically charged to the clients nominated card or bank account after the session has concluded. Payments for coaching services are non-refundable.
No-Show/Cancellation Policy
In the event that the client is no longer able to attend a booked appointment the Nutritionist should be contacted to reschedule the appointment. Consultation calls cannot be cancelled or rescheduled within 12 hours of the appointment. Cancellations within 12 hours of the appoint will incur a charge of 50% of the consultation fee.
If the client does not show up to a scheduled appointment, the full fee will be charged.
