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Gastrointestinal Health Questionnaire

This questionnaire is designed to provide your nutritional therapist with the necessary information to build a tailored treatment programme. Please answer the questions as accurately as you can. All the details you provide on this form will be held private and confidential.

After completion, return by email to [email protected].

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PERSONAL DETAILS

Name: Date:

Email:

Phone numbers:

Contact address:

GP name & phone:

GP address:

Date of birth: Height: Weight:

Occupation:

Do you give permission for your doctor to be contacted? (tick if yes) Are you currently undergoing medical treatment? Are you currently pregnant or planning a pregnancy?

Do you have any special dietary considerations? (e.g. vegetarian, allergies etc.) Please give details:

Reason for consultation:

Medication/Supplement Condition being treated

1. 2. 3. 4. 5. 6. 7.

OPERATIONS AND ILLNESSES Please list any major operations and illnesses that you have had (if any). Also include any ongoing complaints such as hayfever, arthritis, migraines etc.

Year Details

1. 2. 3. 4. 5. 6. 7.

Please tick the boxes that apply to you. 1 = Regularly (Click on the box and a tick will appear) 2 = Sometimes 3 = Never

SECTION ONE 1 2 3 1 2 3

Bloating/belching shortly after meal Heartburn shortly after meal Sense of ‘fullness’ after eating Undigested food in stool Nausea after taking supplements Rectal itching SECTION TWO Bloating 1-2 hr after meal Constipation or diarrhoea Dairy sensitivity Food allergy or intolerance Arthritis or asthma Sinus or skin problems SECTION THREE Cramping in lower abdomen History of antibiotic use Athletes foot/fungal nail infection Mucus/blood in stool Foul smelling lower bowel gas Loose stools SECTION FOUR Dizzy if standing suddenly Sensitive to bright light Feel stressed Clench or grind teeth Allergies or hives Difficulty getting to sleep SECTION FIVE Stomach upset by greasy food Greasy or shiny stools Light or clay-coloured stools Sensitive to chemicals Have had haemorrhoids (piles) Use prescription medication SECTION SIX Poor/slow wound healing Painful joints Fatigue Crave fatty or greasy food Dry skin or dandruff Brittle Nails

Please state how often you Less than 1-2 times 3-7 times More than consume the following foods. once a week per week per week once a day Meat and Fish Red meat White meat Oily fish White fish Eggs and Dairy Eggs Milk Yoghurt Cream Cheese Fruit and Vegetables Fresh vegetables Tinned vegetables Fresh fruit Tinned fruit Pulses, Beans, Nuts Baked beans Other tinned pulses or beans Dried pulses or beans Nuts Seeds Grains Bread Pasta Breakfast cereal Oats Rice Other type of grain Other foods Take-aways and fast food Baked goods (cakes, cookies etc) Sweets and chocolate Ready meals & packaged foods (burgers, pasties, frozen pizza etc) Beverages Coffee Decaf coffee Tea Decaf or herbal tea Soft drinks (including fruit juice) ‘Diet’ soft drinks Water

Please list any foods that you …

… crave.

… dislike.

… would find hard to give up.

Do you eat when … Bored Stressed On the go In front of TV (Tick all that apply.)

Do you enjoy cooking? Yes No Sometimes

Do you skip meals? Yes No Sometimes

How often do you eat out? Never Occassionally Frequently

Are you following a special diet (give details)?

How many units of alcohol do you drink each week? One unit = ½ pint beer or 1 measure spirits or 1 small [125ml] glass wine

On a scale of 1-10, how motivated are you to make dietary and lifestyle changes? Not at all 1 2 3 4 5 6 7 8 9 10 Extremel y motivated motivate d

On a scale of 1-10, how confident are you about making dietary and lifestyle changes? Not at all 1 2 3 4 5 6 7 8 9 10 Extremel y confident confide nt

Please use this box for additional notes if necessary

I confirm that the information provided is correct to the best of my knowledge.