Nutritional Therapy Questionnaire

Name:

First

Last

E-mail:

Date of Birth:

day

month

year

Gender:

Male

Female

Current Weight:

Height:

How many hours do you work/study per week?:

How much exercise do you get each week?

Describe the symptoms you are currently experiencing:

What are three things you would like to gain from this consultation?

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Do you sleep well?

Yes

How do you feel when you wake up?

Do you, or have you ever smoked?:

Yes

If yes, how often and for how long?:

Do you drink alcohol?:

Yes

If yes, how much and how often?

List your 3 common drink preferences:

What role does exercise play in your life?:

How much water do you drink per day?

Are you currently under a practitioners care for a specific health issue?

Yes

If so, what treatments are you undergoing?

Are you currently taking any vitamins/minerals/herbs/homeopathic remedies or any other supplements?

Are you currently taking any prescribed/ non prescribes medications, aspirins, laxatives, antacids, painkillers, contraceptive pill/injection/coil or other medications?

Do you have any known allergies to medications, herbs or food?

Have you the results of any recent medical or diagnostic test e.g endoscopy barium meal, ultrasound, cholesterol, complete blood count, liver enzymes, thyroid levels, hormones i.e. oestrogen/ progesterone/ cortisol or any other test. If so can you please list below with the results/diagnosis or bring a copy to the consultation?

Yes

I've taken the tests but do not have a copy of the results

No, I haven't taken the tests

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Health Checklist

Please answer “Yes” or “No”. Leave a blank if the symptom does not apply.

General Symptoms

Fainting spells:

Yes

Allergies :

Yes

Frequent Colds/Flu :

Yes

Fatigue:

Yes

Insomnia:

Yes

Frequent illness:

Yes

Ears

Itchy Ears:

Yes

Wet or Weeping Ears:

Yes

Earaches:

Yes

Ringing in Ears:

Yes

Ear Drainage:

Yes

Hearing Loss:

Yes

Eyes

Watery Eyes:

Yes

Itchy or Red Eyes:

Yes

Blurred Vision:

Yes

Tunnel Vision:

Yes

Black Floaters:

Yes

Intermittent Blind Spots:

Yes

Nose

Stuffy Nose:

Yes

Sinus Problems:

Yes

Hay Fever:

Yes

Sneezing:

Yes

Excess Mucus:

Yes

Nose Bleeds:

Yes

Emotions

Mood Swings:

Yes

Anxiety:

Yes

Nervousness:

Yes

Anger:

Yes

Irritability:

Yes

Depression:

Yes

Heart / Cardiovascular

Irregular Heartbeat:

Yes

Rapid Heartbeat:

Yes

Chest Pain:

Yes

Poor Circulation:

Yes

High/Low Blood Pressure

Yes

Joint / Muscle

Joint Pain:

Yes

Arthritis:

Yes

Muscle Pain :

Yes

Varicose Veins:

Yes

Back Pain:

Upper

Mid

Lower

Shoulder Pain:

Yes

Head

Dizziness:

Yes

Headaches:

Yes

Lung/Respiratory

Chest Congestion:

Yes

Asthma:

Yes

Shortness of Breath:

Yes

Bronchitis:

Yes

Chronic Cough:

Yes

Mind

Poor Memory:

Yes

Confusion:

Yes

Learning Difficulties:

Yes

Poor Concentration:

Yes

Energy

Fatigue:

Yes

Apathy:

Yes

Hyperactivity:

Yes

Restlessness:

Yes

Mouth/Throat

Chronic Sore Throat:

Yes

Swollen Gums:

Yes

Receding Gum Line:

Yes

Mouth Ulcers:

Yes

Sensitive Teeth/Nerves:

Yes

Coldsores:

Yes

Diagnosed Medical Conditions

Diabetes:

Yes

Hepatitis:

Yes

Cancer:

Yes

Other:

Digestive Tract

Nausea:

Yes

Diarrhea:

Yes

Constipation:

Yes

Bloating:

Yes

Belching/Burping:

Yes

Excess Flatulence Gas:

Yes

Heartburn/Reflux:

Yes

Urinary Tract

Bladder Trouble:

Yes

Kidney Failure:

Yes

Kidney Infection:

Yes

Kidney Stones:

Yes

Prostate Trouble:

Yes

Chronic UTIs:

Yes

Burning Urination:

Yes

Skin

Acne:

Yes

Boils:

Yes

Hives/Rashes:

Yes

Hair Loss:

Yes

Excess Hair Growth:

Yes

Excess Sweating:

Yes

Dryness:

Yes

Eczema:

Yes

Sensitive Skin:

Yes

Bruising Easily:

Yes

Weight

Binge Eating:

Yes

Cravings:

Sweet

Savory

Excessive Weight:

Yes

Compulsive Eating:

Yes

Water Retention:

Yes

Under Weight:

Yes

Eating Disorder:

Yes

Women

Genital Itch/Discharge:

Yes

Fibrocystic Breasts:

Yes

Hysterectomy:

Yes

Irregular Smear Test:

Yes

Thrust/Yeast Infection:

Yes

Vaginitis:

Yes

Endometriosis:

Yes

Polycystic Ovary Syndrome:

Yes

PMT

Yes

Absence of Period:

Yes

Infertility:

Yes

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*All of your information will remain strictly confidential.