Consultation Record — Emma Crawford Nutrition

1

Client Details

Client Full Name

Date of Birth

Preferred Name

Address

Town / City

Postcode

Phone

Email

GP Name & Surgery

Emergency Contact & Relationship

How did you hear about us?

Consultation Type

Consultation Date

Next Review Date

2

Medical & Health History

2.1 Current Medical Conditions

List all current diagnoses

2.2 Medications & Supplements

Medication / Supplement

Dose

Frequency

Prescribing clinician

2.3 Relevant Medical History

Previous diagnoses, surgeries, hospitalisations, eating disorders, weight management history

2.4 Family History

Additional family history notes

2.5 Previous Weight Management Attempts

Approach tried

When

Result

Reason for stopping

2.6 GLP-1 / Weight Management Medication

Medication name

Current dose

Date started

Prescribing clinic / pharmacy

Side effects experienced

Dose change planned?

3

Measurements & Body Composition

Measurement

Today

Weight (kg)

Height (cm)

BMI

Waist circumference (cm)

Hip circumference (cm)

Waist:hip ratio

Blood pressure

Resting heart rate

3.1 Body Composition — GE CS10G Scales

Metric

Today

Muscle mass (kg)

Body fat %

Visceral fat rating

Body water %

Bone mass (kg)

Protein %

Basal Metabolic Rate (kcal)

Metabolic age

4

Diet & Food History

4.1 Typical Day of Eating

Breakfast — typical time

Breakfast — what / how much

Mid-morning snack

Lunch — typical time

Lunch — what / how much

Afternoon snack

Evening meal — typical time

Evening meal — what / how much

Evening snacks / after dinner

Hot drinks (type, milk, sugar, how many)

Cold drinks (juices, fizzy, energy drinks)

Alcohol — type, frequency, units per week

Water intake per day (approx.)

4.2 Favourite Foods & Meals

Favourite meals (home cooked)

Favourite takeaways / eating out

Favourite snacks

Favourite fruits

Favourite vegetables

Favourite proteins

Comfort foods / foods they'd miss most

Foods associated with reward / celebration

4.3 Food Dislikes, Intolerances & Allergies

Foods they dislike / won't eat

Food allergies (confirmed)

Food intolerances / sensitivities

Dietary requirements

Any texture / sensory aversions

4.4 Eating Patterns & Behaviours

Meal prep — who cooks at home?

How often do they cook from scratch?

Frequency of eating out / takeaway per week

Eating speed

Tends to eat alone or with others?

Eats at a table / desk / in front of TV?

Skips meals? Which ones and why?

Grazing / picking throughout the day?

Emotional / stress eating triggers?

Night-time eating patterns?

Binge episodes? Frequency / triggers?

Relationship with food (client's own words)

4.5 Cooking Skills & Equipment

Confidence cooking from scratch (1–10)

Cooking skills — any gaps?

Time available to cook on weekdays

Time available to cook at weekends

Does food budget affect choices?

Shops at

4.6 Supplements & Functional Foods

Current supplements taken

Protein supplements / shakes

Fortified foods used

Interest in further supplements?

5

Lifestyle & Wellbeing

5.1 Sleep

Typical sleep duration (hours)

Sleep quality (1–10)

Sleep issues

Shift work or irregular hours?

Use of screens before bed?

5.2 Stress & Mental Wellbeing

Current stress levels (1–10)

Main sources of stress

History of anxiety / depression / eating disorder

Current mental health support

Coping strategies currently used

Motivation to change right now

1 = not at all motivated → 10 = extremely motivated

Confidence in ability to change

1 = not at all confident → 10 = extremely confident

Readiness to make changes today

1 = not ready → 10 = ready to start now

5.3 Physical Activity

Current activity level

Types of exercise enjoyed

Exercise frequency per week

Average daily steps (approx.)

Exercise history

Barriers to activity

Injuries / physical limitations

5.4 Work & Daily Routine

Occupation

Working hours / pattern

Desk-based or active job?

Work travel / commute?

Eating at work

Access to fridge / microwave at work?

5.5 Social Life & Eating Out

Social eating frequency per week

Types of social occasions

Alcohol at social events — impact on eating?

Does social life feel like a barrier?

Support from family / partner re: healthy eating?

5.6 Alcohol Consumption

Typical units per week

Preferred drinks

Binge drinking episodes?

Drinks to relax / cope with stress?

Motivation to reduce alcohol (1–10)

5.7 Smoking & Substance Use

Additional notes

6

Psychological Profile & Habit Assessment

6.1 Relationship with Food & Body

How does the client describe their relationship with food?

Any history of disordered eating?

Body image — how do they feel about their body?

Do they weigh themselves? How often?

Do they use food tracking apps?

What does 'healthy eating' mean to them?

6.2 Eating Triggers & Habit Patterns

Trigger notes / patterns described by client

6.3 Habit Change Readiness

Stage of change

Biggest perceived barrier to change

What would need to change for this to feel possible?

Previous successes in behaviour change (any area)

Client's strengths identified

Habit stacking opportunities identified

7

Clinician Assessment & Consultation Notes

7.1 Clinical Impression

Summary of initial assessment — key factors, risk areas, opportunities

7.2 Nutritional Priorities Identified

Priority notes

7.3 Key Discussion Points from Consultation

What was discussed, key messages delivered, client response, any concerns raised

7.4 Agreed Next Steps

Action plan issued?

Referrals made

GP communication needed?

Resources / handouts given

Follow-up appointment booked

Follow-up date

Anything to carry forward to next session

7.5 Safeguarding / Concerns

⚠️ Safeguarding

Note any safeguarding concerns, risk flags or mental health concerns here. If action was taken, document what was done and when.

7.6 Clinician Signature & Date

Clinician Signature

Sign here

Date

Print name & role

Terms & Conditions

Location

Contact