HEALTH QUESTIONNAIRE
Please complete all questions as carefully and as accurately as you can.
PERSONAL INFORMATION Name
Address
Tel (work)
Tel (home)
Tel (mobile)
Date of Birth
Height
Weight
Occupation
GP’s details (your GP will not be contacted without your permission)
GENERAL HEALTH INFORMATION Main Health Concern(s) to be addressed
What triggers these condition(s)?
How long have you had these health concern(s)?
Please list any health conditions, operations or accidents that you have had in the past (e.g. - childhood asthma, gall bladder removal etc).
What treatment was given and how effective was it?
1 Do you currently take any medications? Please note what they are for, the name and dosage.
Please list any medical or functional test results that you have available, (or attach them to this form).
Do you currently take any supplements? Please note why you are taking them, who prescribed them, the brand and dosage.
Please underline if any of the following apply to you: Pain: any pain which is persistent or severe in head, abdomen, chest, eye or temple, on passing urine, or any other. Bleeding: blood in sputum, vomit, urine, or stool. Changes in: appetite, bowel habit, passing of urine, skin, personality / behaviour, body / face shape, vision, breathing, swallowing. Are there any particular illnesses or conditions in your blood relatives? (e.g. - heart disease, cancer etc.) If so please state which disease(s) and which relative(s).
GENERAL DIETARY ANALYSIS (Please note that this information is in addition to your 5 day food diary)
Do you have any dietary restrictions? (e.g. – vegan, vegetarian etc).
How often do you normally choose white bread, pasta or rice?
How often do you eat biscuits or cakes?
On average, how often do you eat dairy products such as milk, cheese, yogurt or butter etc?
On average, how often do you eat wheat products such as bread, pasta, cakes and biscuits?
On average, how many portions of fresh fruit do you eat each day?
On average, how many portions of vegetables or salads do you eat each day?
On average, how many cups of caffeinated tea or coffee do you drink each day? Do you add salt to your food?
Do you add salt when cooking?
2 On average, how many glasses of water do you drink each day?
How often do you eat deep fried foods?
How often do your eat barbequed foods?
How often do your eat smoked meat or fish?
How often do you eat processed foods (e.g. – processed cheese, processed meat etc)?
How often do you eat take aways?
How often do you eat ready meals?
Do you usually boil or steam your vegetables?
Do you experience any bloating or fatigue after eating any foods? (If yes please state which).
CARDIOVASCULAR HEALTH Do you have a personal or family history of high blood pressure? (If personal please state reading if known).
Do you have a personal or family history of high cholesterol? (If personal please state level if known).
Do you have a diagnosed cardiovascular disease?
Do you suffer from heart palpitations? How often and when do they occur?
How often do you exercise each week? What type of exercise do you do?
Do you suffer from chest pains? How often and when do they occur?
Are you prone to putting weight on around your middle?
On average, how many units of alcohol do you drink per week?
What kind of alcohol do you drink?
Do you smoke? (If yes, how many cigarettes do you smoke per day or week?) On average, how many portions of oily fish do you eat per week?
On average, how many portions of red meat do you eat per week?
GLUCOSE TOLERANCE 3 Do you need to eat frequently (e.g. – every few hours)?
If you don’t eat for more than 3 hours do you feel:
Irritable? Unable to concentrate? Less focused? Headache? Shaky? Tired? Weak? Anxious or nervous? Crave tea, coffee or cigarettes? Crave sweet foods or drinks? Very often, do you experience:
Excessive urination? Excessive thirst? Excessive appetite? Sweet smelling breath? Unintended weight loss? Excessive weight gain?
ADRENAL STRESS Do you experience excessive sweating?
Do you have difficulty building muscles?
Do you have difficulty falling asleep?
Do you suffer from low blood pressure? (Please state reading if known).
Do you find it difficult to cope with stressful situations?
Are you prone to food allergies or food sensitivities? (Please state which).
Do you suffer from cold hands and/or feet?
Do you crave salt or salty foods?
Do you feel tired after doing exercise?
Do you feel light headed or dizzy when standing up?
Do you suffer from fatigue which is not relieved by sleep?
Do you find it hard to get up in the morning?
Do you feel rundown or overwhelmed?
THYROID FUNCTION
4 Do you feel tired and sleep excessively?
Do you find it difficult to lose weight?
Do you feel sensitive to the cold?
Do you suffer from poor digestion and/or constipation?
Do you have dry and/or thickened skin?
Do you tend to feel sluggish?
Do you find that your thinking and/or movements are slow?
Do you have problems with memory and/or concentration?
Do you have coarse or thinning hair?
Have you noticed that you lose hair from the outer third edge of your eyebrow? Do you suffer from explained depression or find it difficult to cope?
Do you have less interest in sex that you used to?
Have you had a miscarriage?
Are you infertile?
Do you have menstrual irregularities?
FEMALE HEALTH Have you had fertility problems? (Please describe).
Do you have heavy, prolonged and/or painful periods? (Please describe).
Do you have irregular periods?
Do you suffer from PMS? (Please describe).
Are you trying to become pregnant?
Are you pregnant? If so, how many weeks?
Are you breastfeeding? If so, how old is your baby?
Do you use the contraceptive pill or IUD?
Do you take HRT? If so, how long have you taken it for?
TOXIC EXPOSURE AND IMMUNE HEALTH Do you eat organic foods? If so, how often? 5 Do you wash your fruit and vegetables before eating them?
Do you live in a city or near a busy road?
Do you work with chemicals?
Do you have mercury fillings? If so, how many?
Have you had your mercury fillings recently removed?
Do you use recreational drugs? If so which ones and how often?
Do you filter your drinking water?
Are you prone to frequent colds and/or infections?
Are you prone to cold sores?
Are you prone to thrush and/or cystitis?
ALLERGIES AND FOOD SENSITIVITIES Please list any known food allergies or food sensitivities.
Are there any foods or drinks that you particularly crave?
Please tick if you suffer from any of the following:
Asthma
Hives
Eczema
Hay fever
Migraines
Facial puffiness
Unexplained itching or watery eyes
Dark circles under the eyes
Sinusitis
Excessive sneezing
Constant sore throat or runny nose or excessive mucus production
Joint pain or stiffness 6 Unexplained muscle aches and pains
Itchy skin or skin rashes
Fluid retention unrelated to PMS
Rapid weight fluctuations
Fatigue after meals or certain foods (if so, please note which)
Binge eating
Unexplained depression
Crohn’s disease or ulcerative colitis
Colon cramps
IBS (if so, please briefly describe)
DIGESTIVE HEALTH Are you prone to gastritis or gastric ulcers?
How often, if ever, do you have heartburn?
Do you ever have unexplained stomach pains related to digestion?
Do you ever have a sour taste in your mouth?
Do you eat in a hurry?
Do you have abdominal bloating or excessive flatulence?
Do you ever see undigested food in your stools?
Do you ever have stools that are hard and difficult to pass or constipation?
Do you feel nauseous after taking supplements?
Do you have weak, peeling, split or ridged nails?
Do you feel bloated after eating fruit?
Are you intolerant to alcohol? (i.e. small amounts make you feel ill)
Do you have a yellowish cast to your skin or eyes?
Do you have a family or personal history of liver or gall bladder disease? (Please state which). 7 Do you feel ill or have pain or sickness after eating fatty foods?
Are you stools very light or clay coloured?
How often have you taken antibiotics in your life?
When was the last time you took antibiotics?
Do you have any itching around the rectum?
Do you have any history of parasitic infection? (If so, please briefly describe).
How often do you take NSAIDs (e.g. nurofen)
Do you have difficulty gaining weight?
VITAMINS AND MINERALS Please tick or highlight any of the following which apply to you. Please note that everything applies, regardless of how many times it appears.
8 C A D E
Prone to colds Poor night vision Depression Infertility Prone to infections Eye lesions or ulcers Osteoporosis Miscarriages Slow wound healing Ulcers – gastric or mouth Joint pain or stiffness Anaemia / skin pallor Broken capillaries Acne Bony deformities Cataracts Varicose veins Eczema or psoriasis Arthritis Heart disease Easy bruising Asthma Tooth decay Shortness of breath Bleeding or swollen gums Sinusitis Psoriasis Accelerated ageing Nose bleeds Prone to colds Poor immunity Age spots Anaemic Prone to infections Age over 60 Low sex drive Smoker Stressful lifestyle Spend lots of time in traffic
B1 B2 B3 B5
Numbness in legs Red, burning or gritty eyes Dermatitis Poor stress tolerance Burning feet or hands Sensitive to bright lights Diarrhoea Stressful lifestyle Fatigue Seborrhoeic dermatitis Dementia or severe Rheumatoid arthritis Pins and needles Blurred vision memory loss Apathy Poor concentration Dry cracking or peeling lips Depression Depression Poor memory Mouth cracks (corners) Irritability Dizziness upon standing Headaches Headaches or migraines Fatigue Indigestion / stomach pains High cholesterol Numbness in the feet Sleep disturbance Blood sugar imbalances Allergies / sensitivities Raynaud’s disease
B6 B12 F.A. Biotin
Poor dream recall Anaemia / skin pallor Anaemia / skin pallor Dry greyish skin Mood swings Fatigue Fatigue Seborrhoeic dermatitis Depression Weakness Shortness of breath Scaly facial rash PMS Sciatica Preconceptual Poor hair condition Water retention Smooth, sore tongue Miscarriages Excessive hair loss Heart disease Irritability or moodiness Pregnant Fungal infections Carpal tunnel syndrome Tingling in hands / feet Cardiovascular disease Candida Eczema Poor memory Regular alcohol use Seizures Seborrhoeic dermatitis Age over 60 Heavy blood loss Hearing problems Asthma Allergies
Ca Mg K Fe
Osteoporosis Irregular heart beat Irregular / rapid Anaemia Joint pains / arthritis High blood pressure heartbeat Skin pallor Muscle cramps Low blood sugar High blood pressure Fatigue or listlessness Brittle nails Muscle cramps or spasms Muscle cramps or spasms Excessive hair loss Tooth decay Poor sleep patterns Fatigue Breathlessness Difficulty falling asleep Migraines Slow reflexes Brittle hair or nails Anxiety, nervousness Asthma Constipation Heavy blood loss High blood pressure PMS Water retention Sore tongue Age over 60 Constipation Dry skin Cracks on edge of mouth
Zn Cu Mn Cr
White spots on more than Anaemia Arthritis Low blood sugar two fingernails Skin pallor Disc or cartilage problems Cravings for sweets Stretch marks Bleeding gums Sore knees Cravings for stimulants Poor sense of taste / smell Easy bruising Reduced fertility Drowsiness during day 9 Weight loss Skin sores Blood sugar imbalances Need for frequent meals Slow wound healing Hair / skin depigmentation Hearing loss Lack of energy Susceptibility to infections Depression Tinnitus Poor concentration Infertility Prone to infections Poor sense of balance Anxiety or irritability Depression Cardiovascular disease Atherosclerosis High cholesterol Slow hair and nail growth Acne or greasy skin Hair loss
Se I B EFA
Family or personal history Goiter Osteoporosis Dry skin or eyes of cancer Fatigue Arthritis Dry mucous membranes Cardiovascular disease Weakness postmenopausal Brittle or cracked nails High blood pressure Oestrogen based cancer Eczema High cholesterol Weight gain Psoriasis Mercury dental fillings Depression Excessive thirst Chemical hypersensitivity Hypothyroidism Inflammation Cataracts Fibrocystic breasts Allergic tendencies Age spots Do not eat any seafood Hay fever Asthma High blood pressure High cholesterol Decreased fertility PMS Breast pain Depression
Please note any other information which may be relevant to your health in the box below:
Declaration
I confirm that this information is correct to the best of my knowledge and that I am not withholding any information that may be important.
Date: Signed:
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