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Food Frequency Questionnaire

Please fill and submit the webform below.

Alternatively – please download, print, fill and bring the completed form with you to your appointment.
Download Food Frequency Questionnaire (PDF – 371 Kb)

If you are unable to complete a section of the form, simply ask our administration staff to assist you.

Please note: items marked * indicate mandatory fields.

Diet and lifestyle choices can directly affect treatment outcomes. This questionnaire will assist us in providing you with the highest level of care in achieving best results for your potential treatment and ultimately your overall health and wellbeing.

Patient Details
Count 1/2 cup diced fruit, berries or grapes as one piece.
Count all types, fresh, frozen or tinned. 1 cup of vegetables is considered 1 serve.
Include all types, fresh or toasted and count one bread roll as 2 slices.
Include sugar taken with tea and coffee and on breakfast cereal, etc.
Protein foods include meat, poultry, fish, eggs, dairy, tofu, beans, legumes. A serve is considered the size and thickness of the palm of your own hand.
Do not include Peanuts
Include freshly squeezed juices.
Include all types. A serve is about the size of a ‘fun size’ chocolate bar.
Include herbal tea.
A standard drink is 100ml of wine or 30ml spirit or 250ml beer.