PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Nutritional Assessment Questionnaire
PLEASE READ THIS BEFORE YOUR CONSULTATION
ABOUT YOUR APPOINTMENT
Please complete this questionnaire as best you can. Don’t worry if you cannot answer all the questions, or find some ambiguous.
We will have time to discuss these during your nutritional consultation.
For your first consultation, we will spend about 1 hour discussing your particular health problems or reason for attending,
resulting in a recommended diet, lifestyle and supplement programme for you to follow. If you are under 16 it is a legal
requirement that a guardian or parent be present. Anything you say or any information you give during a consultation is
completely confidential.
TESTS
You may be recommended to have some tests to find out more precisely what is going on. The results of most tests are returned
between 10 days and 3 weeks. At your next consultation results will be discussed with you and you will always be given a copy of
your test results. Tests, however are completely optional and will be explained and discussed in detail.
SUPPLEMENTS
You may be recommended to take a course of dietary supplements. Should you have any problems or questions concerning your
supplement programme please contact me. Please note that any supplement programme is only intended to be used on a shortterm basis whilst you are under my supervision. Also, any treatment programme will be specifically designed for you and may
not have the same effect on other people. Finally, please do check with me before making any alterations to your supplement
programme.
FOLLOW-UP
Follow up consultations will usually take place 3-6 weeks after initial consult and generally last about an hour.
CANCELLATIONS AND MISSED APPOINTMENTS
If you need to cancel an appointment please give 24 hours notice. Failure to do so may incur additional charges.
Missed appointments will be charged at the regular consultation fee.
PAYMENTS
Please note that payment upfront is necessary to secure your booking. Payment can be made via Paypal (link will be sent by
email)
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
By e-mail - Please complete this document online, giving as much information as you can and return to
info@ciararyannutrition.com
If you have any questions regarding the questionnaire or food diary, please contact me by email or phone 087 7955509.
Name:
Address:
Email Address:
Tel:
Occupation:
Weight:
Height:
Age:
Number of Dependents and their ages:
PART I: General Information
Please list up to 5 health concerns, conditions or ailments that you may have for example high blood
pressure, headaches, constipation, fatigue, weight problems, asthma, arthritis etc. If you have none that’s
fine.
Example
Migraines
Thrush
2 years
on/off 10 years
Health Problem
Duration
1
2
3
4
5
What are your aims/goals from your initial consultation?
1.
2.
3.
2
Paracetemol
Canestan
Medication/Management
PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Other than any mentioned above, what medications do you currently take? (state daily dosage and
remember to include painkillers and over the counter medications, inhalers, the contraceptive pill etc).
What medications would you have taken regularly in the past (antibiotics, steroids.... )
What other illnesses have you had in the past 10 years ?
What is your normal blood pressure? (Don’t worry if you don’t know)
Are you pregnant, planning on becoming pregnant or experiencing fertility problems at this time.
Have you had any blood tests done recently and why? Any other tests carried out e.g. colonoscopy,
endoscopy etc?
Do you have a medically diagnosed allergy?
HEREDITY PROFILE
What illnesses is/was your father prone to?
What illnesses is/was your mother prone to?
What illnesses are/were your siblings prone to?
LIFESTYLE (please answer questions as fully as possible to give me a clearer picture of your lifestyle)
How many times do you exercise per week and what type (if any)?
If you don’t exercise, what prevents you from doing so?
What do you do to relax?
Do you feel guilty when relaxing?
Do you smoke? How many per day?
Is your energy less now than it used to be?
Do you spend much time by a TV or computer screen?
Do you have difficulty getting to sleep or staying asleep?
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
PART II
Please tick all of the symptoms that you are experiencing:
Section 1 – Digestion, Absorption and Elimination
Belching or gas within 1 hour of a meal
Do you feel like skipping breakfast
Heartburn or Acid reflux
Do you often feel better if you don’t eat
Bloating
Often sleepy after meals
Bad breath (Halitosis)
Fingernails which chip, peel or break easily
Feel like food gets ‘stuck’
Specific foods upset your digestion, what are
they?
Sense of excess fullness after meals
Do you use indigestion tablets
Hurried eating habits
Undigested foods in stools
Anaemia unresponsive to Iron
Diarrhoea after meals
Stomach upset by taking vitamin supplements
Stomach pains or cramps
Ever had an ulcer or gastritis
Picked up any kind of bug when abroad
Food allergies or sensitivities that you know of
Are there foods you could not give up?
Specific foods make you tired or bloated
Sinus congestion or stuffy nose
Do you suffer from hives?
Sometimes feel “spacey” or ‘foggy’
Airborne allergies (e.g hayfever)
Alternating constipation and diarrhoea
Anal Itching
Less than 1 bowel movement per day
Coated tongue
Stools loose or not well formed
Feel worse in musty or mouldy atmosphere
Irritable bowel syndrome
Fungus or yeast infections (e.g nail fungus, athletes
Blood in stools, black or tarry stools
foot, thrush)
Stools hard or difficult to pass
Mucus in stools
History of parasite infection
Excessive or foul lower bowel gas
Cramps in lower abdominal region
Antibiotic use recently or in the past
Section 2 – Liver and Gallbladder
Pain between shoulder blades
History of drug or alcohol abuse
Stomach upset by greasy foods
History of Hepatitis
Nausea
Long-term use of prescription medications
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Light or clay-coloured stools
Sensitive to chemicals (e.g perfume, cleaning
solvents, insecticides, car exhausts etc)
Gallbladder removed?
Frequent headaches or migraines
Easily intoxicated or easily hungover?
Haemmorhoids
Skin conditions e.g. rashes, itching
Strong reaction to caffeine, palpitations, jittery
etc
Strong reaction to medications e.g. antibiotics,
pill
Bitter or metallic taste in mouth after meals
Pain under right side of rib cage
Particularly sensitive to tobacco smoke?
Section 3 – Cardiovascular
Blood pressure above 140/90
Are you overweight?
Heart palpitations/missed heartbeat
Chest pain or numbness/tingling in left arm
High cholesterol
Do you seldom exercise vigorously ?
Family history of heart disease
Do you smoke, drink, or use recreational drugs?
Section 4– Immune System
Antibiotics on a yearly basis
Itchy skin or dermatitis
Rhinitis
Cysts, boils or rashes
Sinusitis
Cystitis
Any other infections you tend to get?
Frequent colds or flu (more that 2-3 colds per
year)
Difficulty shaking off infections
History of hayfever, asthma, eczema
Cold sores
History of Epstein Bar, Herpes, Shingles,
Chronic Fatigue, Hepatitis or other chronic viral
conditions
Section 5 – Women Only
Are you/have you taken the pill?
Are you/have you taken HRT?
Have you had a hysterectomy?
Have you experienced difficulty getting
pregnant?
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Depression during periods
Breast fibroids – benign masses
Have you entered menopause?
Do you/have you suffered from acne
Mood swings associated with periods
Vaginal discharge and itchiness
Crave chocolate around periods
Vaginal dryness
Breast tenderness associated with cycle
Excess facial or body hair
Excessive menstrual flow
Hot flushes
Minimal blood flow during periods
Endometriosis
Abdominal cramps around period
Irritability around period
Occasional skipped periods
Uterine Fibroids
Section 6 – Adrenal
Insomnia
Crave salt or salty foods
Slow starter in the morning
Joint or muscle pain/weakness
Feel wired or jittery when drinking coffee
Chronic fatigue, or feel drowsy often
Clench or grind teeth
Easily startled or bothered by lights,
sounds etc
Do little things bother you
Is your blood pressure low
Calm on the outside, troubled inside
Tired but wired?
Become dizzy when suddenly standing up
Get second wind at night – after 11?
Section 7 – Thyroid
Difficulty gaining weight, even with large
appetite
Mentally sluggish, reduced initiative
Nervous, emotional, can’t work under
pressure
Easily fatigued, sleeping during the day
Inward trembling
Sensitive to cold - Poor circulation
Flush easily
Chronic constipation
Fast pulse at rest
Difficulty losing weight
Intolerance to high temperatures
Loss of lateral third of eyebrow
Skin and hair dryer than usual
Seasonal sadness
Section 8 – Blood Sugar
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Do you waken at night and find it hard to get
back to sleep
Fatigue that is relieved by eating
Crave sweets
Headaches if meals are skipped or delayed
Do you eat a lot of desserts or sugary snacks
Irritable before meals
Binge or uncontrolled eating
Get shaky if meals are delayed
Excessive appetite
Family members with diabetes
Crave coffee or sugar in the afternoon
Frequent thirst
Sleepy in the afternoon
Frequent urination
Nervousness/anxiety/irritability
Loss of concentration, poor attention span, poor
memory
Section 9 – Stress Profile
Do you anger easily
Is your job stressful
Is your home life stressful
Do you over exercise or overtrain
Do you have decreased tolerance generally
Do you feel frustrated often
Do you do shiftwork
PART III – DIET ANALYSIS
DIET QUESTIONNAIRE
Do you avoid a food or food groups for medical or religious reasons?
Are you following any particular diet at the moment?
Any foods you would find it hard to give up?
What foods do you crave?
What foods do you particularly like?
What foods do you particularly dislike?
Is your diet repetitive?
Do you eat out frequently?
Have you changed your diet in the last few years?
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PRIVATE AND CONFIDENTIAL (This information will not be disclosed to third parties under any circumstances)
Do you cook for yourself?
Do you enjoy cooking?
How many coffees do you drink per day?
How many teas do you drink per day?
How many slices of bread would you eat per day and what type?
Do you drink cows milk?
How much alcohol do you drink in a week and what is your drink of choice?
Do you drink fizzy drinks? How often?
Do you drink tap water?
Do you add sugar to foods/drinks?
Do you use artificial sweeteners
How often do you have takeaway food?
Do you opt for low fat or ‘diet’ versions of foods?
How often do you eat biscuits/chocolate/sweets/cakes?
Please put any additional information that you think might be useful here.
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