Naturopathic Health Questionnaire
“treat the whole; affect the mind; lift the spirit”
Sarah Couchman ND BSc D.O Sp Dip Naturopath
The Wellbeing Clinic
1 Windmill Road Headington Oxford OX3 7BL
The following questionnaire will help to gather information about your health history
and current health status. Please take the time to answer questions as accurately as
possible and return to me at the address below prior to your consultation.
Your appointment will last between 1 and 1 1/2 hours so that further clinical
assessments any questions can be answered fully. Please endeavour to arrive on
time for your appointment. If, for any reason, you need to reschedule your
appointment, please inform myself directly or contact the clinic on the number below
at the earliest convenience, this will avoid a cancellation charge. Cancellation fee of
full payment will be charged when a cancellation is made with less than 48 hours
notice. This ensures other clients are able to use the appointment time.
Enquiries: 01865 751111 Mobile: 07810354407
Private and Confidential
First Name:
Last Name:
Address:
Email Address:
Tel:
Mobile:
Date of Birth:
Occupation:
Weight:
Height:
GP:
GP Surgery:
Please list current medical complaints in order of severity:
Symptoms
Length of time this has
been happening
1
2
3
4
Please list any medication you are currently taking (include contraceptive pill, herbs,
vitamins, minerals etc)
Medication
1
2
3
4
Dose (if
known)
Length of time you
have been taking
this medication
Heredity Profile
What illnesses are/were the following prone to?
Your
Father
Your
Mother
Your
Siblings
Your
Children
What illnesses did you have as a child? (e.g. Measles, Polio, Ear Infections, Mumps,
Chicken Pox, Appendicitis, German Measles, Tonsilitis)
Did you reject milk or any other foods as a child?
Do you have any known allergies? Please list:
Do you suffer frequent colds/viruses/infections?  Yes  No
Have you been diagnosed with any illnesses? (e.g. IBS, colitis, hernia)
Do you have gum disease or any other dental/mouth problems?
Have you had any operations including removal of organs? Please give approximate
dates.
How frequently do you move your bowels?
 Daily
 Following meals
 Infrequently
Are stools easy to pass?
 Yes
 No: is this a recent problem and/or associated with other
problem (e.g. piles)?
Have you noticed blood or mucus in your stools?
 Recently
 In the past
Lifestyle
Are you under any stress at the moment?  Yes  No
If yes, are these stressors related to your health or environmental/social factors?
Do you work more than 60 hours per week?  Yes  No
Are you especially competitive?  Yes  No
Do you feel you worker harder than most people you know?  Yes  No
Are you exposed to chemicals at work?  Yes  No
If yes, please give details:
How much time per day do you spend in front of a screen (TV/VDU)?
Do you spend more than 2hrs a week driving?  Yes  No
Do you smoke more than 5 cigarettes per day?  Yes  No
Do you live or work in a smoky atmosphere?  Yes  No
Do you drink over 1 unit of alcohol per day?  Yes  No
What do you prefer to drink?  Wine
 Beer
 Spirits
Do you easily become angry?  Yes  No
How many times do you exercise per week?
Is your energy less now than it used to be?  Yes  No
Do you feel guilty when relaxing?  Yes  No
Are you unclear about your goals in life?  Yes  No
Do you have difficulty getting to sleep?  Yes  No
How would you describe your emotional character?
Have you suffered from significant bereavement/severe trauma/separation in the last
5 years?
Have you had any accidents? (e.g. falls, car accidents, broken bones)
What makes your problems better or worse?
Nutritional Profile
Please tick the food groups you eat every day and answer following questions:
 Meat (Fish, beef, lamb, pork, turkey, chicken)
-how many times per week do you eat white meat (fish or poultry)?
-how many times per week do you eat red meat (beef, pork, lamb or game)?
 Dairy (milk, cheese, yoghurt)
-how many pints per week?
-what type of milk?
 Vegetables and fruit (any fruit, green or yellow vegetables)
-do you wash fruit and vegetables before preparing/eating?
 Cereals (bread, biscuits, cooked or cold cereal)
-do you normally eat white rice or products made with white flour?
-how much bread or rolls do you eat per day?
Please indicate the amount you have of the following:
Per day
Cups of tea or coffee
Sugar in tea or coffee
Adding salt to food
Snacks
Per week
Fast food
Canned or frozen food
Fried food (chips etc)
Chocolate/sweets
What snacks do you eat during the day? (e.g. crisps, nuts, dried fruit, biscuits)
Do you use a water filter or drink bottled water instead of tap water?
Do you frequently eat under stressed conditions or on-the move?
Does your job involve eating out a lot?
How would you describe your appetite?
Please shade the following on the clock-faces below:
a) Fatigue: when you feel fatigue during the day
b) Energy: when you have the most energy
c) Sleep: when you fall asleep, when you wake, include naps.
AM
PM
Specific Symptoms
Please tick the problems you have experienced in the last month, as well as
indicating whether these have been an issue in the past.
Belching or gas within 1 hr of
eating
Heartburn acid reflux
Bloating after eating
Bad breath
Using indigestion tablets
Feeling excessively full after
eating
Eating quickly
Anaemia (unresponsive to
iron)
Pain between shoulder
blades
Nausea
Stomach upset by greasy
foods
Brown spots on skin
Light or clay-coloured stools
Chronic fatigue or
Fybromyalgia
Upper Gastrointestinal System
Current Past
Feeling like skipping
breakfast
Feeling sleepy after meals
Chipped/easily broken nails
Stomach pains/cramps
Feeling better if you don’t eat
Upset stomach after taking
vitamins
Diarrhoea after meals
Undigested food in stools
Liver and Gallbladder
Current Past
Drug or alcohol use in
response to stress
Hepatitis
Long term use of prescription
medications
Easily intoxicated by alcohol
Hurried eating habits
Sensitive to chemicals (e.g.
perfume, solvents,
insecticides, car exhausts)
Current
Food alleries
Abdominal bloating 1-2 hrs
after eating
Specific foods make you
tired or bloated
Pulse speeds up after eating
Airborne allergies (e.g.
hayfever)
Current
Never get sick
Runny nose
Cough producing mucus
Frequent infections: ear,
sinus, lung, skin, bladder
Small Intestine
Past
Hives
Asthma, sinus infection, stuffy
nose
Sometimes feel “spacey” or
unreal
Alternating constipation and
diarrhoea
Feeling as though there are
foods you cannot give up
Immune system
Past
Itchy skin or dermatitis
Cysts, boils or rashes
Frequent colds or flu
Epstein Bar, Mono, herpes,
shingles, chronic fatigue
Current
Past
Current
Past
Current
Past
Current
Past
Current
Heavy breathing
High cholesterol
Family history of heart
disease
Dizziness
Short of breath on exertion
Blood pressure above
140/90
Discomfort at high altitudes
Fluid retention (e.g. swollen
ankles)
Current
Insomnia
Slow starter in the morning
Feel wired or jittery when
drinking coffee
Clench or grind teeth
Calm on the outside,
troubled on the inside
Become dizzy on standing
Increased sex drive
Weight gain around face,
waist and hips
Adrenal
Past
Crave salty foods
Muscles easily fatigued
Chronic fatigue, or feel
drowsy
Afternoon yawning
Afternoon headache
Current
Past
Current
Past
Current
Past
Allergies/hives
Loss of appetite
Current
Flush easily/sweat with little
activity
Difficulty gaining weight,
even with large appetite
Nervous, emotional, can’t
work under pressure
Inward trembling
Allergic to iodine
Intolerance to high
temperatures
Fast pulse even when rested
Diarrhoea
Facial, limb laryngeal muscle
spasm
Nausea, vomiting
Increased urination
Cardiovascular
Past
Overweight
Seldom exercise vigorously
Smoke, drink use recreational
drugs
Muscle cramp during exercise
Problems with breathing
Tension or tightness under
breastbone, worse on
exertion
Respiratory problems
Dull chest pain which may
radiate to left arm
Thyroid
Past
Mentally sluggish, reduced
initiative
Easily fatigued, sleep during
the day
Sensitive to cold – poor
circulation
Chronic constipation
Difficulty losing weight
Loss of lateral third of
eyebrow
Seasonal sadness
Thinning hair
Twitching
Anaemia
Loss of appetite
Increased thirst
Current
Wake after a few hours’
sleep, hard to get back to
sleep
Cuts and bruises take a long
time to heal
Eat desserts/sugary snacks
Binge or uncontrolled eating
Excessive appetite
Crave coffee or sugar in the
afternoon
Sleepy in the afternoon
Decreased sugar tolerance
Sugar Balance
Past
Fatigue that is relieved by
eating
Past
Current
Past
Current
Past
Current
Past
Headaches if meals are
skipped or delayed
Irritable before meals
Shaky if meals are delayed
Frequent thirst
Family members with
diabetes
Frequent urination
Crave sweets
Experience PMS/PMT
Infertility
Poor memory/ concentration
Essential Fatty Acids
Current Past
Dry eyes
Excessive thirst or sweating
Dry, flaky skin or dandruff
Vulnerable to insect bites
Numbness/itching/tingling in
extremities
Depressed
Pale skin
Easily exhausted
Teeth grinding
Unable to remember dreams
Small bumps on back of
arms
Decreased sense of
smell/taste
White spots on fingernails
Strong food odour
Vitamin and Mineral Needs
Current Past
Sore tongue
Worrying, apprehensive,
anxious
Muscles easily fatigued
Slow wound healing
Bone loss
MSG sensitivity
Take contraceptive pill
Sensitive to strong light at
night
Bleeding gums, especially
when brushing teeth
Muscle cramps
Nosebleeds, bruise easily
Current
Prostate problems
Difficulty starting/stopping
urine stream
Pain or burning on urinating
Pain on inside of legs/heels
Sensation of incomplete
bowel evacuation
Melancholia
Current
Men only
Past
Decreased sexual function
Waking regularly at night to
urinate
Chronic constipation
Low energy, tire easily
Nervousness in legs
especially at night
Current
Depression during periods
Breast fibroids – benign
masses
Crave chocolate around
periods
Excess facial or body hair
Excessive menstrual flow
Minimal menstrual blood flow
Occasional skipped periods
Water retention
Thrush
Problems with pregnancy
Post menopausal
Women only
Past
Mood swings (PMS)
Breast tenderness associated
with cycle
Vaginal
discharge/itchiness/cystitis
Vaginal dryness
Hot flushes
Endometriosis
Uterine fibroids
Bloating
Trying to conceive
Symptoms of menopause
Taking HRT
Current
Past
While this questionnaire is very comprehensive, there may be problems or issues yet
raised, which you feel are relevant to your assessment.
Please outline any other issues not covered:
Thank you for taking the time to fill in the questionnaire, please return it with your
deposit to Sarah Couchman 30 Beaumont Street Oxford OX1 2NY.
Sarah Couchman ND BSc DO Naturopath
Mob: 07810354407