Health Pre-Screening Questionnaire

This questionnaire helps us understand if you are within our Scope of Practice as a Nationally Recognised Nutritionist (NRN). Please answer honestly. All information is confidential.

Basic Information

Full Name *

Email Address *

Phone Number *

Age *

Health Screening NCA CRITICAL

Have you been diagnosed with any of the following conditions? *

Diabetes Heart Disease High Blood Pressure Kidney Disease Liver Disease Cancer (current or recent) Eating Disorder Mental Health Condition None of the above

ℹ️ If any chronic conditions are selected, you may be referred to an Accredited Practising Dietitian (APD) or your GP for specialized care.

Are you currently taking any prescription medications? *

Yes No

Are you currently pregnant or breastfeeding? *

Pregnant Breastfeeding No

⚠️ Pregnant or breastfeeding clients require specialized nutrition care from an APD.

Your Goals

What are your primary nutrition goals? *

Improve general health Healthy weight management Increase energy Improve digestion Maintain cultural food traditions

Nationally Recognised Nutritionist (NRN)
Certificate IV in Nutrition (11046NAT)
Governed by Nutrition Council Australia (NCA)

📞 0490 521 111

📧 info@resonantnourish.com

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