All details on this questionnaire will be
held PRIVATE AND
CONFIDENTIAL.
This questionnaire is designed to
provide your nutritional therapist with
all the information necessary to
facilitate a nutritional programme
tailored to your specific needs.
Please answer all questions as
accurately as possible.
First name: ________________ Last name: _________________DOB:______________
Address:
GP Name:
GP Address:
Landline:
Mobile:
Telephone:
Email:
Email:
Occupation:
Blood pressure (if known):
Weight:
Height:
Cholesterol levels (if known):
Please sign below to confirm that the information given on this form is correct to the
best of your knowledge; that you understand nutritional advice is not intended to
replace the advice of a medical practitioner or medical treatment. 24 hours notice is
required to cancel or reschedule a consultation.
Please tick the box if you would like to receive monthly recipes, information and health tips □
Signature: ___________________________ Date ___________________________
1
Are you currently seeing your GP for any health problems?
If so, please list any medications that you currently take?
Have you in the past or are you currently following a medically prescribed diet?
Have you seen/are you currently seeing a nutritionist, homeopath or other health
practitioner (please specify)?
Please list any nutritional supplements, herbs, homeopathic and other remedies you
are currently taking and why, giving manufacturer’s name and dosage (please bring
with you to consultation if possible):
Any hobbies/forms of relaxation:
Exercise (please specify):
Would you describe yourself as:
sedentary □
moderately active □
active □
very active □
What are your reasons for the consultation/ what are your current health goals (in
preference)?
1.
2.
3.
2
PERSONAL HISTORY
Please outline all significant health problems starting with the most recent:
Health problem
Medication/management
Duration
e.g Eczema
Antihistamines
2010-2012
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Below is a list of symptoms associated with nutritional deficiencies. Please mark all relevant
symptoms as indicated. Some symptoms are repeated- please mark them each time they
occur. C= current RP=Recent past P= Past
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Acne
Bumps on skin
Burning eyes
Cataracts
Dry eyes
Dry hair
Dry skin
Dull hair
Itchy eyes
Inflamed eyelids
Peeling nails
Poor night vision
Rigid nails
Rough skin
Thickened skin
Tired eyes
Ulcers
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Bleeding gums
Gingivitis
Easy bruising
Enlarged veins under tongue
Pallor
Red pimples on skin
Short of breath
Slow wound healing
Thread veins
Varicose veins
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Excess wrinkles for age
Pallor
Shortness of breath
Slow wound healing
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Constipation
Dry eyes
Dry hair
Dry mouth
Dry skin
Dry vagina
Eczema
Excess thirst
Lifeless hair
Rough skin
Slow wound healing
Ulcers
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Dermatitis
Eczema
Grooved tongue
Painful gums
Red tongue tip
Raw tongue
Scaly skin
Shiny/glossy tongue
Smooth tongue
Sore mouth
Tooth decay
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Burning feet
Eczema
Hair loss
Painful tongue
Teeth grinding
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Cracks at corners of mouth
Painful tongue
Pallor
Raw tongue
Red tongue
Scaling/cracked lips
Shortness of breath
Smooth tongue
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Easy bruising
Eye bleeds
Gum bleeding
Heavy menstrual bleed
Nose bleeds
Pallor
Prone to fractures
Shortness of breath
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Brittle nails
Dandruff
Dry skin
Eczema
Hair loss
Pallor
Scaly skin
Shiny/glossy tongue
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Hair breaks easily
Poor growth
Poor muscle mass
Slow wound healing
Split nails
Water retention
3
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Bone pain
Fracture risk
Frequent stool
Frequent sore throat
Leg cramps
Light sleep
Tender muscles
Unsound sleep
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Acne
Cracks at corners of mouth
Dermatitis
Eczema
Flaky skin
Hair loss
Oily skin
Painful tongue
Pallor
Shiny/glossy tongue
Shortness of breath
Water retention
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Cracks at corners of mouth
Crusty eyes
Dermatitis
Hair loss
Loss of eyebrows
Painful tongue
Purplish tongue
Scaly skin
Shiny/glossy tongue
Watery eyes
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Difficulty walking
Pallor
Raw tongue
Red tongue
Red tip of tongue
Shiny/glossy tongue
Shortness of breath
Smooth tongue
Ulcers
____ Food cravings
____ Obese
____ Weight gain
____
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____
Difficulty hearing
Difficulty walking
Numbness
Premature ageing
Sore knees
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Brittle nails
Eczema
Leg cramps
Muscle spasms
Poor growth
Prone to fractures
Tooth decay
____ Dandruff
____ Loose skin
____ Premature grey hair
Constipation
Hair loss
Inflamed tongue
Lifeless hair
Pallor
Poor exercise tolerance
Poor skin tone
Shiny/glossy tongue
Shortness of breath
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Excess wrinkles for age
Lax joints
Pallor
Reduced skin pigment
Shortness of breath
Skin sores
Weakness
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Acne
Bumps on skin
Dandruff
Dry skin
Hair loss
Oily hair
Poor appetite
Poor night vision
Poor smell
Poor taste
Premature grey hair
Slow growth
Slow wound healing
Short of breath
Stretch marks
Ulcers
White flecks on nails
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Constipation
Dry hair
Dry skin
Leathery skin
Swollen neck
Voice has deepened
Weight gain
4
C= Current RP= Recent past P=Past
Digestion Profile
Cardiovascular Profile
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Abdominal pain
Anal Irritation
Bloating
Black stool
Blood in stool
Rushing meals/eating on the go
Coated tongue/bad breath
Constipation or
bowel movement less than once a
day
Diarrhoea
Eat when stressed
Fatty meals difficult to tolerate
Gall stones
Haemorrhoids/piles
Indigestion/heartburn
Irritable bowel syndrome
Kidney stones
Mucus in stools
Nausea or vomiting
Not chewing thoroughly
Pain under right rib
Pale stools
Passing wind/flatulence/belching
Parasite Infection
Reflux
Thrush
Use of antacids
Use of antibiotics
Use of antifungals
Worms
Glucose Tolerance Profile
____ Craving sweet foods or stimulants
____ Drowsiness in the afternoon or
after eating
____ Headaches
____ Weak/irritable/dizzy/shaky if miss
meals
____ Fatigue/lack of energy
____ Mood swings
____ Needs to sleep a lot
____ Need for frequent meals
____ Poor concentration/memory
____ Feel unrefreshed after waking/
rising
____ Tendency to depression/low
moods
____ Thirsty a lot
____ Frequent urination
____ Weight fluctuations
____
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____
Active
Abdominal weight gain
Anaemia
Blood clots
Blue extremeties
Calf pain
Chest pain
Dizziness on standing
High or low blood pressure
High cholesterol
High triglycerides
Irregular or rapid heart beat/
palpitations
Migraines/headaches
Pain in legs while walking
Peripheral vascular disease
Poor circulation/cold hands and
feet
Regular exercise
Smoker
Stressed
Thread veins
Varicose veins
Weight control difficulties
Inflammation Profile
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Acne
Arthritis
Asthma or bronchitis
Back pain
Breast tenderness
Cancer
Conjunctivitis or pink eye
Crohn’s Disease
Dermatitis
Ear infections
Eczema
Flaky, itchy skin
Food allergy
Food Intolerance
Gastritis (inflamed stomach lining)
Gingivitis (inflamed gums)
Hay fever
Hives
IBS
Joint pain or stiffness
Mastitis (breast infection)
Nephritis
Oesophagitis
Pancreatitis
Pelvic inflammation
PMS/PMT
Prostatitis
5
Allergy Profile
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Anaphylaxis/carry epipen
Bed wetting
Bloating
Excess mucus
Facial pain/sinusitis
Headaches/migraines
Itchy ears/nose/mouth/throat
Insomnia
Learning difficulties
Mouth ulcers
Moods (anxiety, depression,
irritability)
Poor memory/concentration
Rashes
Red/itchy ears
Sneezing
Swollen lips
Swollen throat
Tired after eating
Water retention
Watery eyes
____ Psoriasis
____ Rashes
____ Rhinitis/ sinus problems
Stress Profile
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Anxiety/tension
Crave salty foods
Difficulty sleeping/insomnia
Dizzy on standing
Extreme exhaustion
Fatigue/low energy
Hair loss
Hot flushes/night sweats
Irritable/easily angered
Low body temperature
PMS/low sex drive
Restlessness
Severe or recurrent stress
Slow recovery from stress
Sweat a lot
How well do you respond to stress:
0= Poorly 5= Reasonably well 10= Very well
Score 0-10 ____
Have you been tested by a doctor?______
Toxicity
List foods and/or chemicals that you react to:
_______________________________
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Hormone Profile
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Abdominal weight gain
Acne
Coarse hair/skin
Cold extremities
Constipation
Depression
Difficulty losing weight
Drug use-medicinal/recreational
Dry skin/hair
Excessive thirst
Excessive urination
Excessive hair growth
Feel faint without food
Hair loss
High blood pressure
High thyroid function
Low sex drive
Low blood pressure
Low thyroid function
Low energy/fatigue particularly
after lunch
Poor memory
Poor concentration
Sweating
Swollen neck/goitre
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Allergies
Chemical sensitivity
Coated tongue
Dark circles under eyes
Dark urine
Dehydration
Drug use- medical
Drug use- recreational
Dull headaches
Exercise near heavy traffic
Exposure to moulds
Fatigue/lethargy
Hangover feeling
Headaches
High intake of additives and
preservatives
High intake of oily fish
High intake of red meat
High intake of processed foods
Hormone imbalance/problems
Irritability
Itching
Joint pains
Live in a city
Live on/near a farm
Low fibre intake
Mercury fillings
Muscle aches
Night sweats
Offensive body odour
Offensive breath
6
Age of first period? _____
Female only Yes= Y No= N
Any history of :
Cysts____
Endometriosis____
Fibroids____
Hormone cancer____
PCOS- Polycystic ovarian Syndrome____
Breast lumps ____
Heavy periods ____
Hot flushes ____
Infertility ____
Irregular periods ____
Mastitis ____
Painful periods ____
PMS ____
Scant/light periods ____
Vaginal bleeding ____
Vaginal discharge ____
Vaginal dryness ____
Do you currently use the contraceptive pill?
Do you have an IUD fitted? State which
Are you currently pregnant?
Planning a pregnancy?
Are you undergoing fertility treatment?
____ Offensive urine
____ Pesticide exposure
____ Prone to colds/infections
Toxicity cont’d
____ Regular alcohol intake
____ Smoker
____ Thrush/candida
____ Tinnitus/ringing in the ears
____ Travellers diarrhoea
____ Rashes
____ Water retention
____ Work with paints/chemicals
____ Worms/parasites
Are you menopausal or post menopausal?
Currently use natural hormones?
Currently using HRT?
Male only Yes=Y No=N
Any history of:
Altered urine flow? ____
Enlarged prostate (BPH)? ____
Hormone cancer? ____
Impotence? ____
Infertility? ____
Low sperm count? ____
Low sperm motility? ____
Prostatitis? ____
7
Dietary Analysis
Please tick where relevant:
____ Add salt to food or when cooking?
____ Add sugar to food/drinks?
____ Consume fizzy drinks regularly?
____ Consume ready meals/sauces regularly?
____ Mainly cook with vegetable oils?
____ Regularly eat fried foods?
____ Regularly eat processed foods/meats?
____ Regularly eat cakes and biscuits?
____ Regularly eat salted/roasted nuts?
____ Regularly eat take-away meals?
____ Regularly eat chocolate?
____ Eat a lot of dairy products?
____ Eat red meat more than twice weekly?
____ Eat oily fish more than twice weekly?
____ Eat three or more vegetable portions daily?
____ Eat two or more fruit portions daily?
____ Avoid additives and preservatives?
____ Choose low fat foods regularly?
____ What percentage of food is home cooked?
____ Consume tea/coffee daily-more than two?
____ Drink more than two units of alcohol daily?
____ Regularly drink herbal teas?
____ Drink 4 or more standard glasses of water daily?
____ Eat mainly wholegrain bread/pasta/cereals?
____ Regularly eat beans and lentils?
____ Regularly eat nuts and seeds?
____ Use butter/margarine for cooking?
____ Regularly eat tinned food?
____ Regularly microwave food?
____ Eat out regularly?
____ Cook for more than 1?
____ Enjoy cooking?
____ Find grocery shopping difficult/stressful?
____ Are you vegetarian/vegan?
____ Do you prefer a vegetarian diet?
Any additional dietary information
you consider relevant?
What are your favourite foods?
_________________________________________________________________________________________
What foods do you dislike?
_________________________________________________________________________________________
List any foods you would find difficult to give up:
__________________________________________________________________________________________
8