Nutrition Consultation Service

Please take your time to fill in this questionnaire as thoroughly as possible. We look forward to hearing all about you!
We'll send your package documents via email, so email address is essential. Thank you!

Name *:

Surname *:

Home address:

Email address **:

Please repeat email address *:

DOB *:

Height*:

Weight*:

No of children:

Children Age/Sex:

Occupation *:

Please state your main reason/s for seeking nutritional support:

How did you hear about this service:

Are you pregnant?

Are you aiming to be pregnant?

Do you have a medically identified food allergy or intolerance:

PART 1: MEDICATIONS and SUPPLEMENTS

How many courses of antibiotics have you had in your life?

When was your most recent course of antibiotics?

What condition has been treated?

Please! list below any prescribed drugs IN THE PAST:

Medication	Condition being treated	Frequency	Duration

Comments:

Please list below any CURRENTLY prescribed drugs

Medication	Condition being treated	Frequency	Duration

Please list below any over the counter medicines current OR in the past

Comments:

How often do you take antacids?

How often do you take aspirin/ paracetamol or any other pain medication?

Please list below any vitamins, minerals, herbs or other Supplements current OR in the past

Comments:

Are you open to supplement (both nutrient and herb) suggestions?

PART 2 - HEALTH HISTORY

Please provide a detailed account of your FAMILY health history to the best of your knowledge

Health Conditions and ailments

Maternal Grandfather

Paternal Grandfather

Maternal Grandmother

Paternal Grandmother

Father

Mother

Brothers

Sister

Personal Health history

Were you born by caesarean section?

Were you breastfed?

Did you have your tonsils removed and at what age?

Did you have any of the following childhood illnesses?

Mumps

Measles

Whooping cough

Chicken pocks

Did you receive childhood vaccinations?

Did you take antibiotics or pain medication as a child?

Were you raised on a healthy diet?

How would you describe your overall health as a child?

Starting with the most current, please list in the space provided all significant health problems that you have encountered in your lifetime. Indicate, where appropriate, the duration, timing and management of the health problem.Please continue in the comment box provided if necessary

Health problem	Management	Duration/Frequency	Date of first occurrence

Comments:

How often do you experience a cold a year?

PART 3 - KEY SYMPTOMS

Please tick if you experience any of the following

any unexplained pain	chest pain	persistent nose bleeds
bleeding from nipple	difficulty swallowing	shortness of breath
blood in respiratory mucous	excessive thirst	slurred speech
blood in stool	frequent urination	unexplained bruising
blood in urine	loss of appetite	unexplained loss of periods
blood in vomit	breast lumps	unexplained weight loss

If you have ticked any of the above please elaborate with further information

Comments:

PART 4 - WEIGHT HISTORY

Please tick if you experience/d any of the following and elaborate in the box provided if necessary.

Whooping cough

Fast metabolism

Do you gain weight easily?

Do you lose weight easily?

Sudden weight loss

Unexplained weight loss

Intentional weight loss

Water retention

Where do you tend to gain weight?

Are you happy with your weight?

What is your ideal weight?

Please provide a short account of your weight history from childhood to present in the box below

Comments:

PART 5 - SLEEP

Please tick as appropriate or elaborate in the box provided if necessary:

asleep after midnight

difficulty waking up

disordered sleeping pattern

feel sleepy during the day

feel un-refreshed after sleep

Insomniac

need less than 7 hours sleep

need more than 8 hours sleep

shift worker

wake up during the night

How many times do you wake to go to the toilet during the night?

Do you nap during the day?

Comments:

PART 6 - Energy

Please tick as appropriate or elaborate in the box provided if necessary

Energy best evenings

Energy best mornings

difficulty getting to sleep

difficulty getting up

exhaustion

fatigue

feel tired all the time

fluctuating energy throughout the day

lethargic

low energy

Comments:

PART 7 - Digestion and Assimilation

Please tick as appropriate or elaborate in the box provided if necessary

Bloating:

Other:

How long does the bloating last?

can't tolerate fatty meals

can't tolerate large meals

eat on the move

Are you a fast eater

Are you a slow eater

eat when stressed

flatulence

heartburn

indigestion

pain under right shoulder-blade

reflux

Comments:

PART 8 - Elimination

Please tick as appropriate or elaborate in the box provided if necessary

anal irritation

blood/black stool

constipation

How often do you pass stools?

Are they easy to pass?

infrequent bowel action

offensive stool

well formed stool

stools that float

stools that sink

How often do you experience diarrhoea?

haemorrhoids

mucus or pus in stool

Comments:

PART 9 - Inflammation

Please tick as appropriate or elaborate in the box provided if necessary

Acne

arthritis

asthma

Do you use an inhaler?

boils

bronchitis

Date of first occurrence?

cardiovascular disease

conjunctivitis

Date of first occurrence?

Frequency?

Crohn's Disease

cystitis

Date of first occurrence?

Frequency?

diverticulitis

eczema

Date of first occurrence?

Is it stress related?

nephritis

oesophagitis

otitis media

pancreatitis

pelvic inflammatory disease

prostatitis

psoriasis

rhinitis

sinusitis

SLE

Mouth ulcers

Stomach ulcers

urethritis

gastritis

gingivitis

hayfever

herpes

hepatitis

Hives

IBS

Infections

joint pains

laryngitis

labyrnthitis

mastitis

Comments:

PART 10 - Toxic Load and Detoxification

Please tick as appropriate or elaborate in the box provided if necessary

Do you consume a lot of artificial additives and preservatives?

How many (if any) amalgam fillings do you have?

Did you have amalgam fillings removed?

Does caffeine keeps you awake?

Do you tolerate caffeine well?

Do you have cellulite?

Do you have chronic headaches?

Do you have a coated tongue?

Do you experience frequent colds/infections?

Do you have dark circles under the eyes?

Do you have dark coloured urine?

Do you often feel dehydrated?

Do you or have you ever used recreational drugs?

Do you suffer from dull headaches?

Do you exercise by busy main roads?

Do you often suffer with a feeling of a being hung over?

Do you feel worse in damp weather?

Have you ever suffered from food poisoning?

Last occurrence?

Frequency?

Please tick if any of the following apply to you:

frequent air travel

gall-bladder problems

high electrical exposure

high exposure to domestic moulds

high exposure to pesticides

high intake of oily fish

high intake of red meat

Small amounts of fruit or vegetables

live in a polluted environment

low fibre intake

low nutrient dense diet

Frequent muscle aches, not exercise related?

nail infection

offensive body odour

offensive breath

offensive urine

play golf regularly

Do you consume processed foods regularly?

Alcohol consumption

How many alcoholic drinks on average a week?

Do you binge drink?

Do you mainly drink red wine or beer?

Do you mainly drink spirits?

sensitivity to chemicals

signs of premature ageing

How many cigarettes do you smoke a day?

When did you start smoking?

Did you smoke in the past?

For how many years?

When did you stop smoking?

Do you frequently experience thrush?

Is it cycle related?

Can you connect it to specific foods you have eaten?

Please tick as appropriate:

athletes foot

tinnitus

traveller's diarrhoea

unexplained itching/rashes

use garden chemicals frequently

Verucas /warts

unwashed fruit and vegetables

work in a polluted environment

worms or parasites

yellow discolouration of skin/eyes

Comments:

PART 11 - This section will help us to determine your potential for allergies:

Please tick as appropriate and elaborate in the space provided

	Comments
Family history of allergies
Diagnosed allergy
History of a severe allergic reaction
Carry adrenalin injections for emergency use
Hospitalised for allergies
Experienced an anaphylactic shock
Been tested for allergies

Please list the foods and/or chemicals that you react to:

Tick as appropriate:

excess mucus	foggy brain	migraines	post-nasal drip
face-ache	genital itch	When did it start?	itchy skin
learning difficulties	sneezing	Frequency?	joint aches
swollen throat	tired after eating	Cycle related?	skin rashes
mouth ulcers	watery eyes	After specific foods?	swollen lips
itchy eyes	poor concentration	In a specific area of head?	palpitations
poor memory

Comments:

PART 12 - This concerns women ONLY

are you considering fertility treatment?	experience complications in labour?
are you planning for a baby?	Please specify:
are you pregnant?	experience complications in pregnancy?
How many weeks?	Please specify:
do you have periods?	experience difficulty breast-feeding?
are your periods regular?	experience difficulty conceiving?
How long is your cycle?	How long did it take you to conceive?
Do you have regular well-woman check-ups?	Experience normal deliveries?
Do you, or have you had an IUD fitted?	Have you been diagnosed with high thyroid?
Have you taken the contraceptive pill?	--If yes elaborate in the comments box
If yes, how long for?	Have you been diagnosed with low thyroid?
If yes, when did you stop?	--If yes elaborate in the comments box
Are you still taking it?	Have you experienced a miscarriage?
Why are you taking the pill?	How many?
Do you take HRT?	Have you experienced a stillbirth?
Have you been on HRT in the past?	How many?
How long for?	Have you had a hysterectomy?
Why have you been on HRT?	When?
	Why?
	Have you received infertility treatment in the past?
	Have you received IVF?
	have you taken hormones for any other reason? If Yes, please elaborate:

Comments:

Age of first period?

Age of final period?

breast cancer	excessive hair growth	low body temperature	sore breasts
lumpy breasts	excessive sweating	low sex drive	swollen neck/goitre
cervical cancer	feel cold	osteoporosis	uterine cancer
coarse hair/skin	fibroids	ovarian cancer	vaginal dryness
cold extremities	Frequency?	ovarian cysts	vaginitis
diminished sweating	When diagnosed?	Frequency?	history of bulimia
dry hair/skin	Fractures	When diagnosed?	hot flushes
endometrial cancer	How many?	painful intercourse
endometriosis	hair loss	painful periods
Age of diagnosis	heavy periods	abdominal pain?
Do you find clots?	high blood pressure	Back pain?

Cycle related headache?	history of anorexia	PMS
		Please elaborate:

PART 13 - This section concerns MEN only

altered urine flow	diminished sweating	Impotence	prostatitis
benign prostatic	dry skin, face & hands	When did it start?	prostate cancer
hyperplasia	excessive sweating	Is it stress related?	swollen neck/goitre
hypertrophy	hypospadias	Infertility	testicular cancer
coarse hair	infrequent need to shave	low sperm motility	undescended testicle
loss of hair colour	loss of hair	low sperm count	urinary frequency
cold extremities

PART 14 - Stress

addicted to any foods	excessive thirst	lack of sex drive	panic attacks
Which ones?	feel cold	low blood pressure	poor co-ordination
addicted to any stimulants	clammy skin	nausea without food	Crave sugary foods
Which ones?	blurred vision	need for frequent meals	palpitations
clumsy	dizziness	recently bereaved	unhappy at home
changed jobs	exposure to pollutants	legal problems	redundancy/retirement
competitive	feel too hot or too cold	multi task	regular drug use
dazzled by lights	financial loss	new parent	relax easily
dizzy from sitting to standing	job promotion	personal achievement	shift worker
physical injury	unclear about your goals	recently married
unhappy at work	recently moved house	recently separated

Comments:

PART 15 - Circulation and transport

anaemia	diabetes	high fat diet	red face
angina	excessive exercise	high triglycerides	shortness of breath
thread veins	groin pain	lung disease	crease in ear
blue extremities	high blood pressure	minimal exercise	varicose veins
atherosclerosis	high cholesterol	pain in legs when walking	water retention
blood clotting disorder	calf pain	peripheral vascular disease	chest pain

Comments:

PART 16 - Unique characteristics

intolerant to dietary changes	addictive/obsessive nature	all girl family
multiple sclerosis	all boy family	crowded upper front teeth
sensitive digestive tract	cry easily	difficulty remembering dreams
vulnerable immune system	excess salivation	early greying hair
light sleeper	little body hair	morning nausea
stretch marks	sneeze in bright sunlight	pale skin
broad chest	tolerates pain poorly	white marks on finger nails
curly hair	creative	dreams a lot
energetic	intuitive	fine/silky hair
dry warm skin	tolerates pain well	fine/shapely hands
good sleeper	little body hair	small, narrowly spaced teeth
gregarious nature	heavy jaw	powerful muscle tone
physically stocky	short neck	Would you describe yourself as:
little dental decay	low hair-line

Please indicate any other diagnosed health problem you have or have had in the past that has not been mentioned so far.

Comments:

PART 17 - Exercise

How many times do you exercise per week?

Do you exercise for longer than 30 min a time at a raised heart rate?

Do you regularly walk to work/shops/the dog?

Do you enjoy exercise?

What type of exercise do you enjoy?

If you do NOT exercise, what has prevented you so far?

Please give an example of your daily diet including times:

Weekday breakfast:

Weekday lunch:

Weekday Dinner:

Weekday snacks:

Weekday drinks:

Weekend breakfast:

Weekend lunch:

Weekend dinner:

Weekend drinks:

Are there any foods that you crave?

Are there any foods that you dislike?

What are your favourite foods?

Which foods would you find hard to give up?

Were you following a special diet in the past?

Which one and How long for?

Are you following a special diet now?

Which one and How long for?

Do you eat to live?

OR

Live to eat?

Do you:	Do you:
cater for a special diet in the family?	cook for more than one?
If yes, which one?	Enjoy eating?
eat lots of wheat and dairy products?	enjoy preparing food?
eat out frequently?	have a good appetite?
What sort of food?	mainly purchase organic produce?
Is your diet repetitive?	Is shopping easy for you?

Part 18

How many biscuits in a week?	How many eggs a week?
How many cakes/pastries in a week?	How many glasses of water a day?
How many cups of coffee a day?	How many raw salads in a week?
How many cups of tea a day?	How many tomatoes a week?
How many pints of milk a week?	How much cheese a week?
How many chocolate bars in a week?	How many slices of bread a day?
Quantity of red meat* in a week?	How many portions (palm size) of
Quantity of white fish in a week?	broccoli a week?
Quantity of oily fish in a week?	cabbage a week?
Quantity of Poultry in a week?	carrots a week?
	vegetables a day?

Part 19

Do you:	Do you:
add salt to cooking or food?	avoid additives and preservatives?
add sugar to food or drink?	choose mainly low-fat food?
drink decaffeinated tea or coffee?	drink mainly bottled water?
frequently add prepared pickles and vinegar to meals?	drink mainly filtered water?
frequently add prepared sauces and ketchups to meals?	drink mainly organic beverages?
mainly cook with vegetable oils?	eat mainly fresh fruit and vegetables?
mainly drink tap water?	eat mainly organic produce?
mainly eat white bread?	eat mainly wholegrain bread, pasta & cereals?
mainly use margarines?	regularly drink herbal teas?
regularly eat fried food?	regularly eat beans and lentils?
regularly eat processed food?	regularly eat seeds?
regularly eat ready prepared meals?	wash/peel chemically treated fruit and vegetables?
regularly eat salted and roasted nuts?	Do you have a food processor or blender at home?
regularly eat smoked and barbecued food?	Do you take a packed lunch to work/school?
regularly eat take-away meals?	How much time do you have for breakfast on a working day?
Do you have to cook dinner in a rush?
	Which supermarket/s do you shop in?

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Supplement	Condition being treated	Frequency	Duration	Current	Past

Please take your time to fill in this questionnaire as thoroughly as possible. We look forward to hearing all about you! We'll send your package documents via email, so email address is essential. Thank you!

Please take your time to fill in this questionnaire as thoroughly as possible. We look forward to hearing all about you!
We'll send your package documents via email, so email address is essential. Thank you!