Nutritional Health Questionnaire

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Your Personal Details

Name

First name* Last name*

Date of Birth

YYYY

Age

Sex

male

female

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

E-mail

Phone number

Occupation

Work environment

Your Health Profile

What is your main reason for seeking nutritional advice?

What outcome are you hoping to achieve?

Please list the health problems you would like to focus on.

Health Problems e.g arthritis

Management to date e.g. GP, operation, paracetamol, exercise, etc

Onset Date

Duration

Have you had any recent health tests? Please specify if appropriate

Have you had any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any chronic or niggling health problems? (please give details e.g. High blood pressure, frequent colds, recurrent urinary infections etc.)

Do you suspect your symptoms relate to a particular event or time in your life?

Medication & Remedies

Please list anything you take regularly including gp prescribed medication, self-prescribed medication (e.g. Painkillers) nutritional supplements, herbal or homeopathic remedies.

Remedy

Dose

Condition being treated

Frequency & duration

Antibiotic history: please state when and why you last took antibiotics plus any previous times you can remember:

Please provide details as fully and accurately as possible.

Body Scan

Please check any conditions that you regularly experience...

Eyes:

Burning

gritty

protruding

prone to infection

sticky

itchy

painful

poor night vision

dry

cataracts

sensitive to light

bags

swollen eyelids

blurred vision

double vision

failing eyesight

yellowish

Ears:

blocked

sore

itchy

weeping

watery

overly waxy

creased earlobe

Nose:

Stuffy

congested

runny

frequent nose bleeds

prone to snoring

sinusitis

hay fever

post-nasal drip

rhinitis

sneezing

poor sense of smell

Mouth:

Sore tongue

tooth decay

mouth ulcers

bad breath

sore throats

poor sense of taste

excess saliva

dry mouth

difficult swallowing

hoarse voice

gingivitis

bleeding gums

amalgams

cold sores

Hands:

Dry

cracked

puffy

cold

eczema

sore joints

chilblains

numbness

tingling

clumsy & uncoordinated

poor circulation

Skin:

Dry

rough

flaky

red

scaly

puffy

pale

oily

brown patches

prematurely lined

clammy

coarse

yellow

pimples

congested

spotty

Skin prone to:

Acne

rosacea

eczema

dermatitis

psoriasis

rashes

boils

hives

itching

cellulite

thread veins

ringworm

easy bruising

excessive sweating

varicose veins

allergic reactions

stretch marks

Nails:

Fragile

dry

brittle

flaky

ridged

peeling

splitting

hangnails (split cuticles)

spoon shaped

white spots on more than 2 nails

horizontal white lines

thickened or ‘horny

dark nails

pale nail bed

infected

Legs & Feet:

Restless legs

swollen

aching

athlete’s foot

fungal toenails

burning feet

tender heels

gout

cold feet

tingling

numbness

prickling

Body Scan Pt. 2

Please check any conditions that you regularly experience...

Mind:

Forgetful

difficulty learning new things

easily confused

difficulty concentrating

easily frustrated

easily distracted

hyperactive

difficult to make decisions

can’t switch off

loss of interest in daily life

fogginess

dyslexia

dyspraxia

panic attacks

no motivation

Head:

Headaches

migraine

stiff neck

fuzzy headed

dizziness

poor balance

pounding head

feeling of hangover

Hair:

Oily

dry

poor condition

brittle

thinning

increased body hair

dandruff

increased facial hair

prematurely grey

increased body hair

decreased body hair

Chest:

Frequent colds/chest infections

asthma

bronchitis

diagnosed heart condition

chest discomfort or pain

short of breath

difficulty breathing

wheezing

persistent cough

noisy breathing

palpitations

Gut:

Bloated

cramping

tender

distended

nausea

sensation of fullness

diarrhoea

acid reflux

heartburn

flatulence

belching

churning

sharp pain

irritable bowel syndrome

coeliac

hiatus hernia

diverticula

polyps

haemorrhoids

sensitive constipation

ulcers

sluggish

Genitals:

itchy skin

cystitis

thrush

painful

ulcers

warts

herpes

groin pain

pelvic inflammatory disease

unexplained discharge

impotence

painful intercourse

vaginal dryness

prostatitis

excessive urination

Muscles:

tender

sore

cramps

spasms

twitches

loss of tone

wasting

weak

stiff

frozen

‘restless legs’

numbness

Joints:

Fingers

knees

shoulders, back etc.

painful

inflamed

swollen

stiff

rheumatic

arthritic

aching

sore

difficulty bending

reduced mobility

unsteadiness

slow movement

Mood:

Please tick your predominant states - even if they conflict:

depressed

anxious

tense

angry

happy

sad

balanced

optimistic

pessimistic

tired

can’t be bothered

hyperactive

cheerful

agitated

easily upset

tearful

jittery

frightened

explosive

pent up

worried

annoyed

overwhelmed

fluctuating

aggressive

Important Symptoms

Please indicate by underlining if you suffer from any of the following symptoms which may require additional medical care:

Unexplained pain

blood in sputum, urine, stools

breast lumps

calf swelling

change in nature of moles

difficulty swallowing

excessive thirst

frequent urination

inability to gain weight

loss of appetite

paralysis

slurred speech

unexplained bruising

rash

or weight loss

unexplained bleeding or discharge from nipple, vagina or rectum

Your Vital Statistics

What is your normal blood pressure?

What is your resting pulse rate?

What is your blood type?

What is your current weight?

What is your height?

What is your hip circumference?

What is your waist circumference?

Is your weight stable, increasing or decreasing?

Stable

Increasing

Decreasing

Did you have the normal immunizations as a child?

Yes

Your Family History

Grandparents:

Parents:

Siblings:

Children:

Your Daily Life

Do you enjoy your daily life?

Yes

Do you feel supported by people around you?

Yes

Have you moved house or changed jobs recently?

Yes

Are you under significant stress in any way?

Yes

Do you work long or irregular hours?

Yes

Is your workload bigger than you can manage?

Yes

Do you feel guilty when you are relaxing?

Yes

Do you have a strong drive for achievement?

Yes

Do you often do 2 or 3 tasks simultaneously?

Yes

Do you take regular exercise?

Yes

Is your job active?

Yes

Do you have any active hobbies?

Yes

Do you sleep well?

Yes

What do you do for relaxation?

Your Environment

Do you live, exercise or work in a city or by a busy road?

Yes

Do you drink unfiltered water?

Yes

Do you drink alcohol?

Yes

How many units a week?

What is your normal alcoholic drink?

Do you smoke?

Yes

How many a day?

Do you think you may be addicted to anything?

Yes

What?

Do you live in a smoky atmosphere?

Yes

Do you sunbathe a lot?

Yes

Are you a frequent flyer?

Yes

Are you exposed to chemicals through work or hobby?

Yes

Do you regularly take antacid (indigestion) medication?

Yes

Roughly what percentage of your food is organic if any?

Do you frequently fry or roast food at high temperatures?

Yes

Do you regularly eat browned or barbecued foods?

Yes

Do you eat oily fish or shellfish more than 3 x a week?

Yes

Do you regularly consume artificial sweeteners?

Yes

Your Digestion

Do you regularly experience...

Indigestion (after food or between meals?)

Yes

Indigestion after fatty food?

Yes

Bowel movement shortly after eating?

Yes

Frequent stomach upsets or stomach pain?

Yes

Nausea or vomiting?

Yes

Pain between the shoulders or under the ribs?

Yes

Constipation or hard-to-pass stools?

Yes

Diarrhoea or ‘urgency to go’?

Yes

Blood or mucus in stools?

Yes

Undigested food in stools?

Yes

Generally inconsistent bowel movements?

Yes

Anal itching?

Yes

Thrush or cystitis?

Yes

How many bowel movements do you have in 24 hours?

Have you noticed any recent change in bowel habit?

Yes

Have you ever had a stomach upset after travelling?

Yes

Is your stool colour pale, mid brown, dark brown, black, clay, grey?

Have you linked any foods to digestive problems?

Yes

Which ones?

Your Energy Levels

Do you need more than 8 hours sleep per night?

Yes

Is your energy less than you want it to be?

Yes

Do you find it difficult to get going in the morning?

Yes

Do you feel drowsy during the day?

Yes

Do you get dizzy or irritable if you don’t eat often?

Yes

What time(s) of day is your energy lowest?

Do you use caffeine, sugar or nicotine to keep going?

Yes

Do you find it difficult to concentrate?

Yes

Do you feel dizzy or light-headed if you stand up quickly?

Yes

Do you suffer from unexplained fatigue or listlessness?

Yes

Women

Are you pregnant?

Yes

How many weeks pregnant are you?

Are you trying to become pregnant?

Yes

Are you breast-feeding at present?

Yes

How many children have you had?

Have you had problems with fertility?

Yes

Have you ever had a miscarriage?

Yes

What contraception do you use?

Are you still menstruating?

Yes

Are you on HRT?

Yes

Are your periods regular?

Yes

Any bleeding or spotting in between?

Yes

Are your periods particularly heavy or painful?

Yes

Do you suffer from PCOS, fibroids, endometriosis?

Yes

Are you happy with your sex drive?

Yes

Menstruating Women:

Please tick if you suffer from:

Pre-menstrual bloating

tiredness

irritability

depression

breast tenderness

water retention

headaches

Other

Menopausal Women:

Please tick if you suffer from:

Hot flushes

insomnia

osteoporosis

mood swings

depression

vaginal dryness

Other

Men

Do you experience mood swings or depression?

Yes

Loss of sex drive?

Yes

Loss of motivation and drive?

Yes

Any known genito-urinary conditions?

Yes

Fertility problems?

Yes

Problems maintaining an erection?

Yes

Frequent or difficult urination?

Yes

Prostate problems?

Yes

Wake at night to urinate?

Yes

Difficult to start or stop urine stream?

Yes

Pain or burning when urinating?

Yes

Eating Habits

What foods do you dislike?

What foods do you crave?

What foods would you find hard to give up?

Do you cater for a special diet in the family?

Yes

Special diet

Who does the cooking in your family?

Do you avoid any food for cultural/ethical reasons?

Yes

Cultural/ethical reasons

Do you suspect any foods don’t agree with you?

Yes

Suspected foods

Have you recently changed your diet?

Yes

Do you eat on the move/when stressed?

Yes

Do you ever have eating binges?

Yes

What do you binge on?

Have you ever suffered from an eating disorder?

Yes

What eating disorder?

Do you chew your food thoroughly?

Yes

Are you excessively thirsty?

Yes

Health Care Providers

Is this your first visit to a Nutritional Therapist?

Yes

How did you find out about me?

GP’s Name

Phone

Address

Are any other therapists/clinics involved in your care?

Yes

Please list:

Signed*

Date*

YYYY

Disclaimer:

I have disclosed all the relevant information applicable to this consultation and my health status at this point in time. I consent for the information provided to be used by my Nutritional Therapist and for my therapist to liaise with appropriate health professionals should this be required.

I acknowledge that this is not designed to provide medical services nor is a health and nutrition consultation being provided as a substitute for a consultation, diagnosis, and treatment by a licensed primary health care professional, such as a Medical Doctor. Products or recommendations in this program are not intended to diagnose, prescribe, or treat symptom, defect, injury, or disease. The information provided is intended to inform, not provide individual medical advice.

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