Back2health Clinic, Squirrels Leap, Ifield Road, Charlwood RH6 0DR
Tel: 07811 385 196
Email:penny@croghan.co.uk
www.back2healthclinic.co.uk
Please consider all questions carefully and answer as accurately as possible
Full name:
Date of birth:
Address:
Telephone no:
DATE:
Mobile no:
Post code:
Email:
Occupation:
Blood type (if known):
Profile 1 – Health Concerns (please list in order of priority and show duration)
.
What helps these problems improve:
What makes these problems worse:
What medications are you taking:
What supplements are you taking:
What operations have you had and when:
Please list any other important points in your medical history (eg gallbladder removed):
Please list any health concerns you have had in the past (eg childhood ashthma, eating disorders etc):
1
www.back2healthclinic.co.uk
Profile 2 (CV) – circle the number of any that apply to you:
1.
2.
3.
4.
5.
Personal history of heart disease
Have a diagonal earlobe crease
High blood pressure
High cholester/blood fat levels
Resting pulse above 80 beats pm
6.
7.
8.
9.
10.
Do NOT exercise regularly
Easily become out of breath
Suffer chest pain on exertion
Drink over 14 units x week
Drink spirits rather than wine
11.
12.
13.
14.
15.
Eat fried foods more than 3 x week
Eat red meat more than 3 x week
Do not eat any nuts or seeds
Do not eat any oily fish
Smoke more than 5 cigarettes x day
10.
11.
12.
13.
14.
Lymph glands swollen or sore
Prone to thrush/cystitis
Have recently taken antibiotics
Have a history of taking antibiotics
Highly or sensitive to stress
Profile 3 (IM) circle the number of any that apply to you:
1.
2.
3.
4.
5.
Personal or family history of cancer
Catch more than 2 colds a year
Prone to infections
Prone to cold sores
Prone to swelling/bleeding gums
6.
7.
8.
9.
Environment/chemical sensitivities
Food intolerances/allergies
Have an auto-immune disease
Have an inflammatory disease such
as eczema
Profile 4 (FI/A) circle the number of any that apply to you:
Please state any known food allergies or intolerances:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Migraines
Facial puffiness
Itchy or watery eyes
Dark circles under eyes
Sinisitis
Excessive sneezing
Constant sore throat
Earache or glue ear
Itchy skin
10.
11.
12.
13.
14.
15.
16.
17.
18.
Tinnitus
Excessive mucous production
General joint pain or stiffness
Muscle aches or pains
Fluctuating fatigue
Fluid retention
Difficulty losing weight
Difficulty gaining weight
Rapid weight fluctuations
19.
20.
21.
22.
23.
24.
25.
26.
Binge or compulsive eating
Food cravings
Hyperactivity
Psoriasis
Eczema
Asthma
Hay fever
Urticaria (hives)
Profile 5 (AD) circle the number of any that apply to you:
1.
2.
3.
4.
Fatigue not relieved by sleep
Hard to get up in the mornings
Poor sleep patterns
Food allergies and intolerances
5.
6.
7.
8.
Irritable, aggressive, less tolerant
High stress/unable to handle stress
Apathy/depression
Energy slump in the afternoons
9.
10.
11.
12.
Feel more more alive in the evenings
Dizzy on standing up
Hard to build muscle/gain weight
Often sweat excessively
9.
10.
11.
12.
Decreased sweating
Low libido, less interest in sex
Infertility, multiple miscarriages
PMS or menstrual irregularities
11.
12.
13.
14.
15.
16.
Shakiness, jitteriness or tremours
Heart palpitations
Excessive or frequent urination
Excessive thirst or appetite
Breath smells sweet
Unintended weight gain/loss
Profile 6 (TH) circle the number of any that apply to you:
1.
2.
3.
4.
Lethargy/fatigue/poor stamina
Weight gain/ difficulty losing weight
Cold hands or feet (sensitive to cold)
Poor digestion, flatulence, bloating
5.
6.
7.
8.
Dry skin and/or coarse hair
Excessive hair loss
Outer third of eyebrow thin/lost
Depression, difficulty coping
Profile 6 (GT) circle the number of any that apply to you:
1. Craving for sweets, chocolate
2. Craving for stimulants (tea, coffee,
cigarettes)
3. Fatigue/weakness if meal is missed
4. Irritability/mood swings if meal missed
5. Feelings of confusion or disorientation
6. Wake from sleep feeling tired or
restless
7. Poor memory and/or concentration
8. Thoughts less focused, more fuzzy
9. Headaches
10. Often feel agitated, easily upset,
nervous
Profile 7 - circle the number of any that apply to you:
2
www.back2healthclinic.co.uk
1.
2.
3.
4.
Usually eat non-organic foods
Do NOT wash fruit/veg before
eating
Eat tinned food more than 3 x week
Live or work in smoky environment
5.
6.
7.
8.
Live/work near a busy road
Live/work near an industrial plant
Usually cycle to work
Work with chemicals
9.
10.
11.
12.
More than 3 mercury fillings
Mercury fillings recently removed
Often us recreational drugs
Normally drink tap water
FEMALES ONLY circle the number of any that apply to you:
1.
2.
3.
4.
5.
If pregnant, how many weeks
Are you trying to become
pregnant
Have you had fertility problems
Heavy periods
Irregular periods
6. Period pains/cramps
7. Do you use contraceptive pill/IUD
8. PMS – anxiety, tension, mood swings
9. PMS – sweet cravings, fatigue, headaches
10. PMS – weight gain, breast tenderness
11. PMS – depression, crying , forgetful
12. Are you peri, post or menopausal
13. Are you taking HRT, if so, for how
long
Profile 8 - circle the number of any that apply to you:
↓HCL
PAR
IP
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
Do not chew food properly
Heavy feeling after meals
Abdominal bloating and discomfort
Excessive flatulence
Constipation or diarrhoea
Weak, peeling, split or ridged nails
IBS – alternating diarrhoea and constipation
Indigestion 1 to 3 hours after eating
Roughage/fibre causes constipation
Itching
1.
2.
3.
4.
History of taking antibiotics or NSAIDS
Multiple food allergies or intolerances
Skin rashes or dermatitis
Unexplained muscle aches
↑HCL
L/GB
1.
2.
3.
4.
History of ulcers or gastritis
Black or tarry stools
Stomach pains
Sour taste in the mouth
1.
2.
3.
4.
5.
6.
Intolerance to alcohol
Yellowish caste to skin or eyes
History of liver/gall bladder disease (in family?)
Fatty foods cause indigestion or nausea
Bitter taste in mouth
Light or clay coloured stools
Profile 9 - tick any that apply to you:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Vit C
Vit A
(ret)
Vit D
Vit E
(toc)
B1
(Thy)
B2
(Ryb)
B3
(Nia)
B5
(Pan)
B6
(Pyr)
3
Frequent colds
Frequent infections
Slow wound healing
Poor night vision
Ulcers – gastric and mouth
Acne
Bone pain
Joint pain
Osteoporosis
Infertility (male/female)
Miscarriages
Anaemia/skin pallor
Fatigue
Numbness in hands
Burning feet or hands
Red, burning or gritty eyes
Sensitive to bright lights
Blurred vision
Acne, rashes or dermatitis
Diarrhoea
Dementia or memory loss
Poor stress tolerance
Poor concentration
Dizziness upon standing
Poor dream recall
Allergies/hypersensitivities
Seborrhoeic dermatitis
www.back2healthclinic.co.uk
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Broken capillaries
Varicose veins
Easy bruising
Eczema
Psoriasis
Dry hair or skin
Bone deformities
Muscle spasm
Muscle weakness
Cataracts
Heart disease
Shortness of breath
Tingling sensations
Poor concentration
Depression
Seborrhoeic dermatitis
Dry, cracking, peeling lips
Mouth ulcers
Depression
Anxiety
Irritability
Apathy
Depression
Teeth grinding
Water retention
PMS
Tingling hands/numbness
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Bleeding, swollen gums
Nose bleeds
Lack of energy, fatigue
Eyes – dry, itchy, red
Respiratory infections
sinusitis
Tooth decay
Hair loss
Psoriasis
Accelerated aging
Age spots
Low sex drive
Irritability
Indigestion/stomach pains
Loss of appetite
Dull or oily hair
Fatigue or sluggishness
Depression
Insomnia
Headaches or migraines
Tinnitus
Poor stamina
Tender/burning feet
Allergies/sensitivities
Heart disease
Mood swings
Depression
o
o
o
o
o
o
o
o
o
B12
(Cob)
Folic
acid
Biotin
o
o
o
o
o
o
o
o
o
Sciatica
Smooth, sore tongue
Irritiability or moodiness
Sore, red tongue
Miscarriages
Infertility
Poor hair condition
Excessive hair loss
Alopecia
o
o
o
o
o
o
o
o
o
Nervousness
Depression
Confusion/poor memory
Diarrhoea
Constipation
Prematurely greying hair
Pale, smooth tongue
Sore tongue
candida
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
brittle nails
tooth decay
insomnia
muscle cramp or spasms
insomnia
hyperactivity
Muscle weakness
Mental apathy
Fatigue, lack of energy
Excessive hair loss
Breathlessness
Brittle hair or nails
Slow wound healing
Susceptibility to infections
Infertility (male/female)
Easy bruising
Skin sores
Hair/skin depigmentation
Reduced fertility
Blood sugar imbalances
Hearing loss
Lack of energy
Drowsiness during the day
Anxiety or irritability
High cholesterol
Heavy metal detox
Chemical hypersensitivity
Excessive thirst
Inflammation
Allergic tendencies
High blood fats
Psoriasis
Hay fever
PMS or breast pain
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
anxiety, nervousness
hyperactivity
high blood pressure
anxiety, nervousness
PMS
Constipation
Constipation
Oedema, water retention
Intense thirst
Heavy blood loss
Sore tongue
Cracks at edge of mouth
Depression
Slow hair or nail growth
Acne or greasy hair
Depression
Prone to infections
Cardiovascular disease
Tinnitus
Poor sense of balance
Atherosclerosis
Poor concentration
High blood fats
High cholesterol
Cataracts
Age spots
Premature aging
Heart disease
Hormonal imbalance
Decreased fertility
Dry skin
Arthritis
Multiple sclerosis
Behavioural changes
Skin pallor
Fatigue
Tingling in hands/feet
Anaemia/skin pallor
Fatigue
Cracking at edge ofmouth
Dry, greyish skin
Seborrhoeic dermatitis
Dry skin
Profile 10 - tick any that apply to you:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Ca
Mg
K
Fe
Zn
Cu
Mn
Cr
Se
EFAs
Ώ3
Ώ6
osteoporosis
bone/joint pains, arthritis
muscle cramps
irregular heart beat
high blood pressure
angina
Irregular/rapid heart beat
High blood pressure
Muscle cramps
Anaemia
Skin pallor
Fatigue or listlessness
White spots on fingernails
Stretch makrs/skin lesions
Poor sense of taste or smell
Anaemia
Skin pallor
Bleeding gums
Arthritis
Disc or cartilage problems
Sore knees
Low blood sugar
Cravings for sweets
Need for frequent meals
Family history of cancer
Cardiovascular disease
High blood pressure
Dry skin
Dry eyes
Brittle or cracked nails
High blood pressure
High cholesterol
Eczema
Asthma
TYPICAL DAILY DIET DIARY
Do you have any dietary restrictions? (eg vegetarian, vegan) ………………………………………..
Breakfast
Lunch
Day 1
Snacks/Drinks/Water consumed per day
4
www.back2healthclinic.co.uk
Dinner
NAET TESTING CHART
Date
Foods/allergens
5
www.back2healthclinic.co.uk