This form helps your dietitian understand your situation before you meet. It takes around 8–10 minutes and is fully confidential.
Please enter your full name
Please enter your date of birth
Please enter a valid email
Please enter your phone number
Please enter your GP surgery
Video call
Phone call
No preference
Please select a preference
Step 1 of 5
Why are you seeing a dietitian?
Select the option that best describes your main reason.
IBS / digestive symptoms
Weight management
Dementia or Parkinson's nutrition
Coeliac disease
Malnutrition / poor appetite / weight loss
Stroke secondary prevention
Pancreatic condition
Other / not listed
Please select a reason
Step 2 of 5
Your health background
General medical information that helps your dietitian understand the full picture.
Yes
No
Step 3 of 5
About your condition
More detail about your specific reason for referral.
Step 4 of 5
Diet & lifestyle
A snapshot of your current eating patterns and daily life.
No specific diet
Vegetarian
Vegan
Halal
Kosher
Gluten-free
Dairy-free
Other
Very poorExcellent
Mostly sedentary
Lightly active (walks, occasional exercise)
Moderately active (3–4x per week)
Very active (daily exercise or physical job)
None
Occasional
Moderate
Heavy
Never
Ex-smoker
Current
Step 5 of 5
Goals & consent
Almost done — tell us what you're hoping to achieve and confirm your consent.
Not at allExtremely motivated
Data protection & privacy
The information you provide is used to assess, plan and deliver your dietetic care at The GCD Clinic. It is held securely, and access is limited to the dietitian responsible for your care.
Your form is submitted through a third-party service acting on our instructions. We do not sell your information or use it for marketing. It will not be shared with anyone else without your agreement, unless required by law or necessary to protect someone from serious harm.
I confirm that I have read and understood how my information will be used