🌿 Let’s Talk

Get in Touch

Ready to make diaita — your way of life — work for you? Reach out, and let’s talk about your goals.

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Reach Us

A few ways to connect

Email

hello.majani@gmail.com

Phone

+33 7 46 42 88 25

Consultations

Online, worldwide — in-person by appointment

Response Time

Within 1–2 business days

Before Your First Session

Nutritional Assessment Form

The more we know about you, the more personalised your plan will be. Fill in as much as you comfortably can — you can always add details later.

Your Nutritional Assessment

Click each section to open it and fill in your details.

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1 Personal Details

First name

Last name

Date of birth

Day

Month

Year

Occupation

Activity level at your job

Height (CM / Feet and inch)

Weight (KG / Pounds)

Age

Gender

2 Contact Details

Phone

Address

City / Town

Postcode

3 Consultation

Main symptoms / reason for this consultation

Any additional concerns you’d like addressed?

Your own lifestyle / wellbeing targets

Your own dietary goals

Your expectations of your practitioner

4 Medical History

Mark all prior / current conditions affecting you

AIDS Alcoholism Allergies Alzheimer’s Anemia Arthritis Asthma Birth defects Bleeding disorder Cancer – breast Cancer – colon Cancer – prostate Cancer – other COPD Depression Diabetes Eating disorders Emphysema Epilepsy Glaucoma Heart attack Heart trouble High blood pressure IBS Kidney disease Liver disease Mental illness Migraine headaches Pneumonia Sickle cell anemia Stroke Tuberculosis Ulcers Other

If you checked « Other », please specify

5 Current Medications & Supplements

Current medications / prescriptions (name, dose, reason, since when)

Current supplements / herbs (name, dose, reason, since when)

Other current therapies

6 Past Medical History

Prior diseases (incl. previously prescribed drugs)

Prior injuries

Prior hospitalisations

Prior surgeries

Prior treatments

7 Allergies

Food allergies (confirmed or suspected)

Mango Strawberries Rice Garlic Oats Meat Milk Peanut Fish Shellfish Soy Tree nut Wheat Hot peppers Gluten Egg Sesame Cocoa Celery Mustard Other

Environmental allergies (confirmed or suspected)

Pollen Cat Dog Insect Sting Mold Perfume Cosmetics Latex Water House Dust Mite Gold Chromium Cobalt Formaldehyde Photographic Developers Fungicide Other

If you checked « Other », please specify

Medicine allergies (confirmed or suspected)

Any food or drink difficult to digest?

8 Lifestyle

Do you smoke cigarettes?

If yes: how long / how many per day / if quit, since when

Do you drink alcohol?

Frequency & average drinks per week

Do you consume caffeinated beverages?

Type & how many glasses/day

Do you use recreational drugs?

Do you exercise regularly?

How often / duration & type of workout

Trouble falling / staying asleep, or waking too early?

Hours of sleep per night

Wake up refreshed, or tired & fatigued?

Bowel movement every day?

9 Women’s Health

Do you take any contraception medication?

Are you pregnant?

How many weeks?

When is your pregnancy due?

Are you breastfeeding?

10 Dietary Information

Food avoided for religious reasons

Beef Pork Lamb

Other foods avoided for religious reasons

Diets followed in the past

Vegan Vegetarian Pescatarian Wheat Free Gluten Free Celiac Grain Free Paleo Raw Low Fodmap Lactose Intolerant Other

Other diets followed (name & when)

How much time are you willing to spend on food preparation?

A quick look at your typical eating pattern

No judgement here — just answer honestly. A full 3-day food diary can be sent by email if you prefer.

Day 1 — typical breakfast, snacks, lunch, dinner

Day 2 — typical breakfast, snacks, lunch, dinner

Day 3 — typical breakfast, snacks, lunch, dinner

Your information is confidential and only used to prepare your consultation.

Thank you! Your assessment has been received — we’ll review it before your session.

Office hours

Monday – Friday9:00 – 18:00
Saturday10:00 – 14:00
SundayClosed

Follow along

Prefer to skip the form? Call or email us directly and we’ll fill it in together during your first call.

Consultations are held online for clients everywhere, with in-person appointments available by request.

Prefer to talk it through?

It’s never too late to start — and it’s better to start where you are than never.

Email us directly

Diaita, Your Way of Life

Real food, real habits, real results — one honest conversation at a time.

Start your assessment