INSTITUTE OF HEALTH AND SOCIETY
MSc NUTRITIONAL THERAPY TEACHING CLINIC
NUTRITIONAL THERAPY CLINIC CLIENT QUESTIONNAIRE
CONFIDENTIAL CLIENT RECORD
DATE
CLIENT NUMBER
NAME AND ADDRESS OF GP
(Your GP will not be contacted without your written consent.)
DO YOU LIVE ALONE, OR WITH A PARTNER / FAMILY MEMBER(S)
/ FRIEND(S)
IF YOU HAVE CHILDREN, PLEASE STATE AGES
WEIGHT
BLOOD PRESSURE (If
HEIGHT
known)
AGE
PLEASE DESCRIBE BRIEFLY THE CONDITION(S) WHICH YOU WOULD LIKE SOME HELP WITH:
DO YOU SUFFER FROM PERSISTENT OR SEVERE PAIN IN ANY OF THE FOLLOWING AREAS:
(Please tick any which apply to you)
Head
Abdomen
Chest
Eye
Other (please state)
Temple
On passing urine
DO YOU EVER GET BLOOD IN ANY OF THE FOLLOWING: (Please tick any which apply to you)
Vomit
Stools
HAVE YOU RECENTLY NOTICED ANY CHANGES IN:
Level of Thirst
Vision
Body/Face Shape
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Weight
Bowel Movements
Swallowing
Urine
Sputum
(Please tick any which apply to you)
Appetite
Urination
Breathing
Skin
Waist Size
Personality
1
HEALTH HISTORY
Please list any serious illnesses, health conditions, accidents or operations you have had (please include childhood)
ILLNESS, HEALTH CONDITION, ACCIDENT OR OPERATION
APPROXIMATE DATE OR ONGOING
(continue on separate sheet if necessary)
PLEASE LIST ALL PRESCRIBED MEDICATIONS YOU CURRENTLY TAKE
NAME OF MEDICATION
DOSE
LENGTH OF TIME TAKEN
PLEASE LIST ANY OVER THE COUNTER MEDICATIONS YOU REGULARLY TAKE
(inc. antacids, pain relief pills, anti-histamines, anti-inflammatory drugs, herbal & nutritional supplements).
NAME OF MEDICATION
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HOW FREQUENTLY TAKEN
TAKEN FOR WHAT PURPOSE
2
HEALTH SCREEN - FAMILY HISTORY
PLEASE INDICATE IF ANY OF THE FOLLOWING CONDITIONS RUN IN YOUR FAMILY - (M = MALE; F =FEMALE)
CONDITION
Grandparents
Paternal
Maternal
M
F
M
F
Parents
Siblings
Children
M
M
M
F
F
F
Alcoholism
Arthritis
Asthma / Eczema / Hay fever
Autoimmune Condition
Cancer
Depression
Dementia
Diabetes
Heart Disease / Stroke / High Blood
Pressure
IBS
Crohn’s, Colitis, Coeliac
Obesity
Osteoporosis
SYMPTOM ANALYSIS
Please tick any of the following symptoms which are relevant to you:
DIGESTIVE
Nausea / Vomiting
White Coated Tongue
Diarrhoea
Difficulty Digesting Fatty Food
Constipation
Poor Sense of Taste or Smell
Bloating
Poor Appetite
Belching and/or Flatulence
Food Cravings
Heartburn
Other (please specify)
Indigestion
EMOTIONS
ENERGY
Mood Swings
Fatigue
Anxiety
Apathy, Lethargy
Anger, Irritability
Difficulty Relaxing
Depression/Low Mood
Difficulty Getting Out of Bed
Spaced Out Feeling
Insomnia
Panic Attacks
Need for Tea/Coffee/Sugary Drinks to keep you going
BLOOD SUGAR CONTROL
IMMUNE SYSTEM
Wake in middle of night feeling anxious.
Frequent Infections
Crave sweet foods.
Frequent need for Antibiotics
Shaky/Irritable when hungry.
History of Antibiotic Use
Sleepy after lunch. Less able to cope/easily upset.
Thrush
Dizzy when standing up suddenly.
Cystitis
Crave salty foods.
Prone to Cold Sores or Mouth Ulcers
Sensitive to bright light.
Sinus Problems
Hay Fever /Asthma / Eczema
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3
NERVOUS SYSTEM
SKIN / NAILS / HAIR
Headaches
Unexplained Hair Loss
Migraines
Acne
Poor Memory
Psoriasis
Confusion
Eczema / Dermatitis
Poor Concentration
Dry Skin
Poor Physical Co-ordination
Excessive Sweating
Difficulty Getting to Sleep
Deterioration of Fingernails
Frequent Waking
White Spots on Fingernails
Puffy Skin.
LIVER
Yellowish Skin or Eyes
Feeling unwell after coffee and / or alcohol.
Tenderness under right ribs.
Bad reaction to chemicals/smells.
EYES
CARDIOVASCULAR
Watery or Itchy Eyes
Palpitations
Swollen, Irritated Eyelids
Swollen Ankles (especially at end of day)
Eyes Feel Gritty
Chest Pains
Dry Eyes
High Cholesterol
JOINTS/MUSCLES
WEIGHT
Aches / Pains in Joints
Compulsive / Binge Eating
Arthritis / Rheumatism
Binge Drinking
Stiffness
Lack of Appetite
Weakness
Water Retention
Shakiness
Difficulty Losing Weight
Muscle Cramps
Difficulty Gaining Weight
Muscle Tension
(eg neck and between shoulder blades)
Crave certain foods (please specify):
WOMEN
MEN
Painful periods
Difficulty urinating
Excessive facial/body hair
Decreased sexual function
Mood swings before period
Urinary tract infections
Heavy Periods
Poor libido
Low libido
Fertility problems
Irregular periods
Waking more than once per night to urinate
Breast tenderness
Fertility problems
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4
DIET AND LIFESTYLE
IS YOUR DIET BASED ON ANY RELIGIOUS, PERSONAL OR OTHER CHOICE?
(eg Gluten-Free, Vegetarian, Vegan, etc)
NO
(please specify)
YES
DO YOU HAVE ANY FOOD ALLERGIES, INTOLERANCES OR SENSITIVITIES THAT YOU KNOW OF OR SUSPECT?
(eg Gluten-Free, Vegetarian, Vegan, etc)
NO
(please specify)
YES
PLEASE LIST 3 OF YOUR FAVOURITE FOODS
•
•
•
PLEASE LIST ANY FOODS YOU REALLY DISLIKE
WHO DOES THE MAJORITY OF COOKING IN YOUR HOUSEHOLD?
HOW MANY TIMES PER WEEK (APPROXIMATELY) DO YOU:
CONSUME READY MADE MEALS?
EAT OUT?
BUY TAKE-AWAYS?
APPROXIMATELY HOW MUCH DO YOU SPEND
ON FOOD EACH WEEK?
£
WOULD YOU BE WILLING TO SPEND MORE?
IF SO, HOW MUCH MORE?
YES
£5
NO
DO YOU SMOKE?
£20
£30
IF YOU USED TO SMOKE, HOW LONG AGO DID YOU GIVE UP?
YES
NO
IF YES, HOW MANY DAYS A WEEK DO YOU NORMALLY DRINK
ALCOHOL?
DO YOU DRINK ALCOHOL?
YES
NO
HOW MANY GLASSES WOULD YOU NORMALLY HAVE PER DAY?
DO YOU NORMALLY DRINK:
Spirits
£10
Wine
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Beer
5
DO YOU EXERCISE REGULARLY?
YES
NO
WHAT TYPE OF EXERCISE DO YOU DO?
ANY OTHER RELEVANT INFORMATION YOU WISH TO ADD
THANK YOU VERY MUCH FOR COMPLETING THIS INFORMATION
IT WILL HELP US TO ADDRESS YOUR PROBLEMS AS EFFECTIVELY AS POSSIBLE.
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6
3-DAY FOOD, DRINK AND DIARY
Please choose 3 fairly typical weekdays and a weekend (or day-off) and record your eating, sleeping and
leisure patterns. Please give as much information as possible: home cooked or not, brand names, fresh,
packaged, whole, refined, organic, skimmed etc and approximate quantities to help your Nutritional
Therapist build an accurate picture of your diet and lifestyle.
DAY 1
TIME
ALL FOOD(S) EATEN (INCLUDE SNACKS) AND DRINKS
e.g. Water, Coffee, Tea, Herbal Juice, Fizzy, Alcohol etc
APPROX.
QUANTITY
OTHER INFORMATION
APPROX.
QUANTITY
OTHER INFORMATION
e.g. Brands, Sugar or Salt Added
DAY 2
TIME
ALL FOOD(S) EATEN (INCLUDE SNACKS) AND DRINKS
e.g. Water, Coffee, Tea, Herbal Juice, Fizzy, Alcohol etc
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e.g. Brands, Sugar or Salt Added
7
DAY 3
TIME
ALL FOOD(S) EATEN (INCLUDE SNACKS) AND DRINKS
e.g. Water, Coffee, Tea, Herbal Juice, Fizzy, Alcohol etc
GUIDE TO ALCOHOL UNITS
APPROX.
QUANTITY
OTHER INFORMATION
e.g. Brands, Sugar or Salt Added
GUIDE TO PORTION SIZES - PLEASE STATE AMOUNT BY:
1 pint strong lager
3 units
Cups
Mugs
1 pint lager, bitter, cider, 175ml of wine
2 units
Tablespoons (tbsp)
Teaspoons (tsp)
1 alcopop
1.5 units
A handful
1 measure spirits
1 unit
Space on a dinner plate (e.g. 1/2, 1/4, 3/4, 1/3)
125 ml wine
1.5 units
Approximate weight.
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Dessertspoons
8