Food Analysis - Jess Keane Nutrition
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• All details on this questionnaire will be held PRIVATE AND CONFIDENTIAL. • Please answer all questions as accurately as possible to facilitate a nutritional programme being designed to best meet your needs. • Date Title Occupation Marital Status Cultural Origins Complete in Word format, save and email back to me at jess@jkn.ie or post to 58 Haven Hill, Summercove, Kinsale, Co Cork. First Name Surname Date Of Birth / / Sex Age/Sex Of Children/Dependants Height (M) Weight (Kg) Address: _______________________________________________________________________________________________ _____________________________________________________________________________________________ Landline: __________________ Mobile: ______________________ Email: _________________________________ GP Name & Surgery Address: _______________________________________________________________________________________________ _____________________________________________________________________________________________ Telephone: ___________________________________ Email: ___________________________________________ Are you currently seeing your GP for any health problems? Is your GP aware of you seeking nutrition support? Do you give permission for your GP to be contacted? Do you give permission for your GP to disclose relevant clinical information to Jess Keane Nutrition? Have you sought professional nutritional advice in the past? Are you currently seeing any other complementary health care practitioner? Have you seen any other health practitioner (other than GP) in the past? Yes / No Yes / No Yes / No Yes Yes Yes Yes / / / / No No No No How you heard about this service? Briefly describe what you hope to gain from nutritional support for the short and long term? Briefly describe what you perceive as your strengths and limitations with regard to your current diet and lifestyle I ________________________________________________________on behalf of (if client is under the age of 16) ___________________________________________ agree to participate in a nutrition consultation. I give my consent to the collection of personal details and information relating to my health, family and diet history. I understand this information will in part be used to devise a nutrition programme and I thereby confirm that all details given are accurate. Please return the questionnaire with a deposit of €35. Please note that a consultation fee of €35 will apply to cancellations with less than 4 8 hours notice. Please tick the box if you would like to receive information on recipes, health tips and events. Signed ______________________________________________ Date __________________________________ PERSONAL HISTORY Starting with your current health concerns please outline all significant health problems that you can remember (including childhood events). Health Problem Duration Management Date Example: Migraines 2 years Migrileve 1996 – 1998 ____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please list all operations under anaesthetic:__________________________________________________________ Have you ever reacted badly to an anaesthetic? YES/NO? If yes, please detail ______________________________________________________________________________________________ Practitioner Comments Please list any nutritional supplements that you currently take: _____________________________ __________________________________________ __________________________________________ Have you taken supplements in the past? If yes, please detail _______________________________ __________________________________________ __________________________________________ Please list any medications that you currently take: __________________________________________ __________________________________________ __________________________________________ Describe any medical tests and results that you have had in the past ______________________________________________________________________________________________ ______________________________________________________________________________________________ Weight History (please use the space below to describe your weight trends over your lifetime i.e. from birth until now) _______________________________________________________________________________________________ _______________________________________________________________________________________________ ____________________________________________________________________________________________ Are you happy with your weight? If not, then please explain further ______________________________________________________________________________________________ ____ ____ ____ ____ ____ ____ ____ ____ ____ Unexplained pain Bleeding from nipple / vagina Blood in sputum / stool Blood in urine / vomit Blurred vision or dizziness Breast lumps Calf swelling Change in nature of moles Loss of appetite Practitioner Comments ____ ____ ____ ____ ____ ____ ____ ____ ____ Numbness / paralysis Chest pain Depression Difficulty swallowing Discharge from vagina Excessive thirst Frequent urination Inability to gain weight Unexplained weight loss ____ ____ ____ ____ ____ ____ ____ ____ ____ Headaches Persistent cough Persistent nose bleeds Shortness of breath Slurred speech Unexplained bruising Heavy periods Loss of periods Unexplained rash FAMILY HISTORY Indicate as best you can which family members were/are prone to any of the following disorders: grandparents GM or GF, parents M or F, sibling B or S, cousins (if known) CM or C F, children CHM or CHF (As a double-check on your own health issues put SF for self if any condition applies to you personally) ________ Addictive/Obsessive ________ Epilepsy ________ Obesity ________ Alzheimer’s disease ________ Fibroids ________ Osteoarthritis ________ Asthma ________ Food Intolerance ________ Osteoporosis ________ Attention Deficit ________ Haemochromatosis ________ Overactive thyroid ________ Autism ________ Hayfever ________ Overweight ________ Cancer ________ Headaches ________ Parkinson’s disease ________ Chemical Sensitivities ________ High blood pressure ________ Polycystic Ovaries ________ Chronic fatigue ________ High cholesterol ________ Poor stress response ________ Coeliac disease ________ Infertility ________ Prematurity ________ Constipation ________ Insomnia ________ Raynaud’s disease ________ Depression ________ Irritable Bowel ________ Rheumatoid Arthritis ________ Diabetes ________ Learning Difficulties ________ Schizophrenia ________ Disordered Eating ________ Migraines ________ Sinusitis ________ Eczema ________ Multiple sclerosis ________ Underactive thyroid ________ Endometriosis ________ Miscarriage ________ Underweight Are your parents alive and well? YES / NO __________________________________________________________ Are your grandparents alive and well? YES / NO _____________________________________________________ (If you answered NO to the above questions please indicate in the space provided the age when either your parent/s or grandparent/s died and as far as you know the cause of their death) Practitioner Comments Digestion & Elimination C = current RP = recent past P = past ____ Abdominal pain ____ Bulky stool ____ Gall stones ____ Anal itching ____ Constipation ____ Haemorrhoids ____ Use of Antacids ____ Can’t tolerate fatty ____ Heartburn ____ Use of Antibiotics meals ____ Hiatus hernia ____ Use of Antifungals ____ Diarrhoea ____ Incomplete motion ____ Black stool ____ Difficulty chewing ____ Indigestion ____ Blood in stool ____ Dry mouth ____ Irritable bowel syndrome ____ Bloating ____ Eat on the move ____ Kidney stones ____ Bolt food ____ Eat when stressed ____ Mucus in stool ____ Bowel action less ____ Excess saliva ____ Morning nausea than once a day ____ Food poisoning ____ Nausea ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Offensive stool Pain under right ribs Painkillers Pale stool Parasites Pus in stool Reflux Stools that sink Stools that float Thrush Worms Practitioner Comments Inflammation C = current ____ Acne ____ ____ Arthritis ____ ____ Asthma ____ ____ Boils ____ ____ Bronchitis ____ ____ Cancer ____ ____ Conjunctivitis ____ ____ Crohn’s disease ____ ____ Cystitis ____ ____ Dermatitis ____ Practitioner Comments RP = recent past Diverticulitis Eczema Food allergy Food intolerance Gastritis Gingivitis Hayfever Heart disease Herpes Hepatitis P = past ____ Hepatitis ____ Hives ____ IBS ____ Infections ____ Joint pains ____ Labyrinthitis ____ Mastitis ____ Nephritis ____ Oesophagitis ____ Otitis media ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Pancreatitis Pelvic inflammation Prostatitis Psoriasis Rhinitis Sinusitis Twisted testicles SLE Ulcers Urethritis Allergy C = current RP = recent P = past ____ Anaphylaxis ____ Mouth ulcers ____ Bed wetting ____ Moods ____ Been tested by doctor (aggression/anxiety/depression) ____ Bloat after eating ____ Poor concentration/memory ____ Carry Epipen ____ Rashes ____ Excess mucus ____ Red ears ____ Face ache ____ Sneeze a lot ____ Growing pains ____ Swollen lips ____ Headaches/migraines ____ Swollen throat ____ Itchy eyes/nose/throat ____ Tired after eating ____ Insomnia ____ Water retention ____ Learning difficulties ____ Watery eyes ____ Were you breast fed? Yes / No Practitioner Comments ____ Toxic Load & Detoxification C = ____ Additives and preservatives ____ Caffeine keeps you awake ____ Cellulite ____ Chronic allergies ____ Chronic headaches ____ Coated tongue ____ Dark circles under the eyes ____ Dark coloured urine ____ Dehydration ____ Drug use including recreational ____ Dull headaches ____ Exercise by busy main roads ____ Exposure to moulds ____ Feeling of a hangover ____ Feel worse in damp weather ____ Gardening regularly ____ High electrical exposure ____ High intake of oily fish current RP = recent P = past ____ High intake of red meat ____ Hormone problems ____ Irritability ____ Itching ____ Joint pains ____ Lethargy ____ Live in a city ____ Live on or near a farm ____ Live near pylons ____ Low fibre intake ____ Mercury fillings ____ Muscle aches ____ Night sweats ____ Offensive body odour ____ Offensive breath ____ Offensive urine ____ Pesticide exposure ____ Premature ageing ____ Addictive/obsessive nature ____ All boy family ____ Cry easily ____ Excess salivation ____ Fast metabolism ____ Little body hair ____ Light sleeper ____ Long fingers and toes ____ Referred itches ____ Sneeze in bright sunlight ____ Tolerates pain poorly List foods and/or chemicals that you react to: ______________________ ____________________________ __ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Play golf regularly High intake of processed foods Regular alcohol intake Regular colds/infections Sensitivity to chemicals Smoke cigarettes Thrush/athletes foot Tinnitus Traveller’s diarrhoea Rashes Verruca/warts Unwashed fruit and vegetables Water retention Weight loss Work with paints/chemicals Worms or parasites Yellow discolouration skin/eyes Practitioner Comments Circulation C = current RP = recent P = past _____ Active _____ Groin pain _____ Anaemia _____ Fatty arteries _____ Angina _____ Hardened arteries _____ Blood clots _____ High blood pressure _____ Blue extremities _____ High cholesterol _____ Calf pain _____ High triglycerides _____ Chest pain _____ Low blood pressure _____ Cold hands/feet _____ Lung disease _____ Crease on earlobe _____ Minimal exercise _____ Enjoy exercise _____ Nose bleeds Practitioner Comments _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Obesity Pain in legs on walking Peripheral vascular disease Red face Smoker Stroke Thick blood Thin blood Thread veins Varicose veins Sleep & Energy C = current RP = recent P = past _____ Addicted to stimulants _____ Anxiety/tension _____ Asleep after midnight _____ Best evenings _____ Best mornings _____ Difficulty getting to sleep _____ Difficulty getting up _____ Disordered sleeping pattern _____ Exhaustion ______ Feel tired all the time _____ Fluctuating energy _____ Heavy sleeper _____ Hyperactive _____ Insomnia _____ Relax easily _____ Shift worker _____ Sleep before midnight _____ Need less than 7 hrs sleep _____ Need more than 8 hrs sleep _____ Un-refreshed after sleep _____ Up after 9am _____ Wake during night _____ Wake refreshed Stressors C = current RP = recent P = past _____ Bereavement _____ Changed jobs _____ Dazzled by lights _____ Dizzy sitting to standing _____ Excessive exercise _____ Financial loss _____ Job promotion _____ Legal problems _____ Marriage _____ Moving home _____ Multi task _____ New parent _____ Overcommitted _____ Palpitations _____ Panic attacks _____ Pain _____ Physical illness _____ Physical injury _____ Redundancy _____ Regular drug use _____ Retirement _____ Separation _____ Unclear about goals _____ Unhappy at home _____ Unhappy at work Please explain your main life stressors ______________________________ ______________________________ ______________________________ Consider your response to stress. Do not compare yourself with others. Only consider how you feel in yourself. (please circle) Good OK Poor What measures do you take to manage stress? ______________________________ ______________________________ ______________________________ Accidents and Injuries Please detail the nature and severity and recovery from any accidents and injuries during your life, with approximate dates. ______________________________ ______________________________ ______________________________ Practitioner Comments Contraceptive Pill: Please indicate whether you have taken the contraceptive pill for contraception and/or hormonal problems? Detail below your pattern of use of the contraceptive pill. E.g. Age 14-16 for period pains, Age 18-25 for contraception, Age 20-30 for acne _________________________________________________________ _____________________________________________________________________________________________ Did you/Do you tolerate the contraceptive pill well? YES/NO If not, please detail side-effects experienced ______________________________________________________________________________________________ HRT: Similarly describe your use of HRT, and whether you tolerate/tolerated well ____________________________ ______________________________________________________________________________________________ Hormonal History C = current RP = recent past P = past _____ Abdominal weight gain _____ Excessive urination _____ Acne _____ Excessive hair growth _____ Crave sweet foods _____ Fast metabolism _____ Crave salty foods _____ Feel cold _____ Coarse hair/skin _____ Feel hot _____ Cold extremities _____ Feel faint without food _____ Constipation _____ Hair loss _____ Depression _____ High blood pressure _____ Difficulty losing weight _____ High thyroid function _____ Dry skin/hair _____ Hyperactive _____ Excessive thirst _____ Low sex drive Practitioner Comments _____ _____ _____ ____ _____ _____ _____ _____ _____ _____ _____ Low blood pressure Low thyroid function Need to eat regularly Poor memory Poor concentration Protruding eyes Regular drug use Sweat a lot Swollen neck/goitre Tired, particularly after lunch Thyroid Medication Women Only Yes = Y No = N _____ Age of first period? Any history of: _____ Endometriosis? _____ Fibroids? _____ Hormone cancer? _____ Miscarriage? _____ Polycystic ovaries? _____ Currently use the contraceptive pill? _____ Did you/have you an IUD fitted? _____ Are you currently pregnant? _____ Planning a pregnancy? _____ Any problems conceiving? _____ Any facilitated conception/s? Men Only _____ Altered urine flow _____ Enlarged prostate _____ Hormone cancer _____ Hypospadias _____ Impotence _____ Infertility _____ Minimal shaving _____ Low sperm count _____ Low sperm motility ______ Painful intercourse _____ Prostatitis _____ Swollen testicles _____ Undescended testes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Any complications in pregnancy? Have you experienced a stillbirth? Did you breast-feed? Any problems breast-feeding? Any complications in labour? Normal deliveries? Any premature births? Regular well-woman checks? Currently use HRT (synthetic)? Currently use natural hormones Any indication of osteoporosis? Age of final period? _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Breast lumps Heavy periods Hormone cancer Hot flushes Infertility Irregular periods Mastitis Painful intercourse Painful periods PMS Scant periods Vaginal bleeding Vaginal discharge Vaginal dryness Practitioner Comments Abdominal Pain All Girl Family Crowded Upper Front Teeth Definite Breath/Body Odour Depression Difficulty Remembering Dreams Early Greying Hair Family History Of Depression _____ _____ _____ _____ _____ _____ _____ Growing Pains Infertility/Miscarriage Irregular Periods Morning Nausea Pale Skin Stretch Marks White Marks On Finger Nails Dietary Pattern Do you: C = current RP = recent P = past _____ Add salt/sugar to cooking or food or drink? _____ Avoid additives and preservatives? _____ Choose mainly low fat foods? _____ Drink more than two coffee’s daily? _____ Drink more than two teas daily? _____ Drink more than 2 units of alcohol daily? _____ Eat a lot of chocolate? _____ Eat a lot of confectionery? _____ Eat a lot of dairy products? _____ Eat a lot of fried food? (not stir fry) _____ Eat a lot of high fat foods? _____ Eat a lot of ready meals? _____ Eat a lot of salty food? _____ Frequently use ready meals or sauces? _____ Eat 3 + portions of vegetables a day? _____ Eat 2 + portions of fruit a day? _____ Eat oily fish more than twice weekly? _____ Eat red meat more than twice weekly? ______ Mainly cook with vegetable oils? _____ Mainly drink tap water? Exercise Pattern _____ Are you very active? _____ Are you moderately active? _____ Are you sedentary? _____ Do you enjoy exercise? _____ Do exercise regularly? If not, please indicate the factors that prevent you from doing so. ______________________________ _____ Mainly use margarine? _____ Regularly drink undiluted juice? _____ Regularly eat beans and lentils? _____ Regularly eat cakes and biscuits? _____ Regularly eat take-away meals? _____ Regularly eat nuts and seeds? _____ Regularly eat processed meats? _____ Regularly microwave food? _____ Regularly wash/peel fruit and vegetables? _____ Eat out frequently? _____ Cook for more than one? _____ Live alone? _____ Enjoy entertaining? _____ Enjoy preparing food? _____ Find shopping easy? _____ Purchase much organic food? _____ Do you prefer a vegetarian diet? Explain any special diet you are following or have followed (including vegan/vegetarian): _________________________________________ _______________________________________ PLEASE NOTE: A full computer analysis with a personalised report incurs a separate charge of €50. Analysis can precede or follow a consultation if requested. This service is available independently of a personal consultation. Please ensure that you give exact timings and quantities/brands of all food and drink that you have. If you have changed your diet recently then please indicate as above a typical prior day on a separate sheet of paper. E.g. 8am 2oz (70g) Kellogg’s cornflakes; ¼ pint semi-skim milk; 1 teaspoon sugar; 1 mug tea with 1 tablespoon semiskim (no sugar) 11am 2 plain digestive biscuits and 1 mug of black coffee Current Typical Weekday from Current Typical Saturday day from Current Typical Sunday from first to last intake - record all food, first to last intake – record all food, first to last intake - include all drink and timings drink and timings food, drink and timings ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ _________________________________ ____________________________ ______________________________ ______________________________ ____________________________ __ List your most favourite foods: Practitioner Comments ______________________________________________ ______________________________________________ List the foods you dislike: ______________________________________________ ______________________________________________ List the foods you would find hard to give up: ______________________________________________ ______________________________________________ Do you eat to live or live to eat? ______________________________________________ ____________________________ Briefly describe your attitude to food ______________________________________________ ______________________________________________ Were you raised on a health diet? Yes / No Food Analysis SIGNS & SYMPTOMS OF POTENTIAL NUTRIENT DEFICIENCIES _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 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 A _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Constipation Dry eyes Dry hair Dry mouth Dry skin Dry vagina Eczema Excess thirst Lifeless hair Rough skin Slow wound healing Ulcers C = current B2 RP = recent past P = past _____ _____ _____ _____ _____ _____ _____ ____ Cracks at corners of mouth Painful tongue Pallor Raw tongue Red tongue Scaling lips Short of breath Smooth tongue F _____ _____ _____ _____ Easy bruising Eye bleeds Gum bleeding Heavy menstrual bleed K SIGNS & SYMPTOMS OF POTENTIAL NUTRIENT DEFICIENCIES _____ _____ _____ _____ Rough skin Thickened skin Tired eyes Ulcers _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Bleeding gums Gingivitis Easy bruising Enlarged veins under tongue Pallor Red pimples on skin Short of breath Slow wound healing Thread veins Varicose veins C _____ _____ _____ _____ Excess wrinkles for age Pallor Shortness of breath Slow wound healing _____ _____ _____ _____ _____ _____ _____ _____ Bone Pain Fracture risk Frequent stool Frequent sore throat Leg cramps Light sleep Tender muscles Unsound sleep _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Cracks at corners of mouth Crusty eyes Dermatitis Hair loss Loss of eyebrows Painful tongue Purplish tongue Scaly skin Shiny/glossy tongue Watery eyes B1 _____ Dandruff _____ Loose skin _____ Premature ageing _____ Food cravings _____ Obese _____ Weight gain _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ A E D BIO Cr Constipation Hair loss Inflamed tongue Lustreless hair Pallor Poor exercise tolerance Poor skin tone Shiny/glossy tongue Short of breath Spoon shaped nails Vertical ridged nails Fe C = current _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Dermatitis Eczema Grooved tongue Painful gums Red tip of tongue Red tongue Raw tongue Scaly skin Shiny/glossy tongue Smooth tongue Sore mouth Swollen mouth Tooth decay _____ _____ _____ _____ _____ Burning feet Eczema Hair loss Painful tongue Teeth grinding _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acne Cracks at corners of mouth Dermatitis Eczema Flaky skin Hair loss Oily skin Painful tongue Pallor Shiny/glossy tongue Short of breath Water retention B6 _____ _____ _____ _____ _____ _____ _____ _____ _____ Difficulty walking Pallor Raw tongue Red tongue Red tip of tongue Shiny/glossy tongue Short of breath Smooth tongue Ulcers B12 _____ _____ _____ _____ _____ Difficulty hearing Difficulty walking Numbness Premature ageing Sore knees _____ _____ _____ _____ _____ _____ _____ Brittle nails Eczema Leg cramps Muscle spasms Poor growth Prone to fractures Tooth decay B3 B5 Mn Ca/Mg RP = recent past P = past _____ _____ _____ _____ K Nose bleeds Pallor Prone to fractures Shortness of breath _____ _____ _____ _____ _____ _____ _____ _____ EFA Brittle nails Dandruff Dry skin Eczema Hair loss Pallor Scaly skin Shiny/glossy tongue _____ _____ _____ _____ _____ _____ P Hair breaks easily Poor growth Poor muscle mass Slow wound healing Split nails Water retention _____ _____ _____ _____ _____ _____ _____ AO Excess wrinkles for age Lax joints Pallor Reduced skin pigment Shortness of breath Skin sores Weakness _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Zn _____ _____ _____ _____ _____ _____ _____ I 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 Constipation Dry hair Dry skin Leathery skin Swollen neck Voice deepened Weight gain Rationale Rationale Rationale Consultation #1 Consultation #2 Date Date Consultation # 3 Date
