OCR Document - Optimum Nutritionists
Contact Details
Address: (Street) ………
(Town) ……… (Postcode)………
Telephone. Work Home: Mobile:
Email:
Consultations – Harley Street London (H) / Oasis Croydon (O) / Tel. (T)
|1st Appointment |Date |Day |Time |
|1st Follow up |Date |Day |Time |
|2nd Follow up |Date |Day |Time |
|3rd Follow up |Date |Day |Time |
|4th Follow up |Date |Day |Time |
Recommended Tests, Action & Results
|Test / Action |Date |Results Received. |Analysis |
| | | | |
| | | | |
| | | | |
PRIVATE AND CONFIDENTIAL - Nutrition & Lifestyle Questionnaire
Today’s Date 7/22/2008 Your Occupation: Hours:
Who do you live with at home?:
Your GP’s/Doctor’s details:
Male/Female D.O.B. Age:
Your Weight (without clothes): stone Ibs kgs Your Height (without shoes): feet inches
Health Profile
Please make a list of all the health problems you would like to clear up and indicate how long you have had these problems e.g.: Headaches 5 years (Continue on a separate sheet if you need more space)
|Health problem |Duration |
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What medications (drugs) do you take for these? (State daily dosage)
Under what circumstances do these problems improve?
Under what circumstances do they get worse?
What other illnesses have you had in the past ten years?
What operations have you had?
What is your normal blood pressure?
Do you consider yourself omnivore? fish no meat eater? vegetarian? vegan? Raw food?
What is your resting pulse rate per minute? (You should be relaxed and sitting down. Your pulse can be found inside the bony protuberance on the thumb side of your wrist. Count beats in 60 seconds.)
Heredity Profile
Do you have any children? (State number, age and sex.)
Are there any particular illnesses that they suffer from?
How many brothers and sisters do you have? (State age and sex.)
What illness is/was your father prone to?
What illness is/was your mother prone to?
SYMPTOM ANALYSIS
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| | | |
|Mouth ulcers |Lack of energy |Dry, rough skin |
|Poor night vision |Diarrhoea |Dry eyes |
|Acne |Insomnia |Frequent infections |
|Frequent colds or Infections |Headaches or migraines Poor memory |Poor memory |
|Dry flaky skin |Anxiety or tension Depression |Loss of hair or dandruff |
|Dandruff |Irritability |Excessive thirst |
|Thrush or cystitis |Bleeding or tender gums |Poor wound healing |
|Diarrhoea | |PMS or breast pain |
| |Muscle tremors or cramps Apathy |Infertility |
|Rheumatism or arthritis |Poor concentration | |
|Backache. |Burning feet or tender heels Nausea or vomiting |Muscle cramps or tremors Insomnia or nervousness |
|Tooth decay |Lack of energy |Joint pain or arthritis |
|Hair loss |Exhaustion after light exercise Anxiety or tension|Tooth decay |
|Excessive sweating | |High blood pressure |
|Muscle cramps, or spasms |Teeth grinding | |
|Joint pain or stiff-ness | |Muscle tremors or spasms |
|Lack of energy |Infrequent dream recall |Muscle weakness |
| |Water retention |Insomnia or nervousness |
|Lack of sex drive |Tingling hands |High blood pressure |
|Exhaustion after light exercise |Depression or nervousness |Irregular heart beat |
|Easy bruising |Irritability |Constipation |
|Slow wound healing |Muscle tremors or cramps |Fits or convulsions |
|Varicose veins |Lack of energy |Hyperactivity |
|Loss of muscle tone |Flaky skin |Depression |
|Infertility | | |
| | |Pale skin |
|Frequent colds |Poor hair condition |Sore tongue |
|Lack of energy |Eczema or dermatitis |Fatigue or listlessness |
|Frequent infections |Mouth over sensitive to hot or cold Irritability |Loss of appetite or nausea |
|Bleeding or tender gums |Anxiety or tension |Heavy periods or blood loss |
|Easy bruising |Lack of energy | |
|Nose bleeds |Constipation |Poor sense of taste or smell |
|Slow wound healing |Tender or sore muscles |White marks on more than two finger nails |
|Red pimples on skin |Pale skin |Frequent infections |
| | |Stretch marks |
|Tender muscles |Eczema |Acne or greasy skin |
|Eye pains |Cracked lips |Low fertility |
|Irritability |Prematurely greying hair Anxiety or tension Poor |Pale skin. |
|Poor concentration |memory |Tendency to depression |
|'Prickly' legs |Lack of energy |Poor appetite |
|Poor memory |Poor appetite | |
|Stomach pains |Stomach pains Depression |Muscle twitches |
|Constipation | |Childhood 'growing pains' |
|Tingling hands |Dry skin |Dizziness or poor sense of balance Fits or |
|Rapid heart beat |Poor hair condition Prematurely greying hair |convulsions |
| |Tender or sore muscles Poor appetite or nausea |Sore knees |
|Burning or gritty eyes |Eczema or dermatitis | |
|Sensitivity to bright lights | |Family history of cancer |
|Sore tongue |Excessive or cold sweats Dizziness or |Signs of premature ageing |
|Cataracts |"Irritability after 6 hours without food |Cataracts |
|Dull or oily hair |Need for frequent meals |High blood pressure |
|Eczema or dermatitis |Cold hands |Frequent Infections |
|Split nails |Need for excessive sleep or drowsiness during the | |
|Cracked lips |day | |
| |Excessive thirst | |
| |'Addicted' to sweet foods | |
LIFESTYLE ANALYSIS (Please underline, BOLD or highlight all that apply)
| | |
|Cardiovascular Profile |Digestion Profile |
|Is your blood pressure above 140/90 |Do you chew your food thoroughly? |
|Is your pulse after 15 minutes rest above 75? |Do you sometimes suffer from bad breath? |
|Are you more than 141bs (7kg) over your ideal weight? |Are you prone to stomach upsets? |
|Do you smoke more than 5 cigarettes a day? |Do you often get a burning sensation in your stomach? |
|Do you do Less than two hours exercise a week? |Do you find it difficult digesting fatty foods? |
|Do you eat more than one spoon of sugar a day? |Do you occasionally use indigestion tablets? |
|Do you eat meat more than 5 times a week? |Do you suffer from flatulence or bloating? |
|Do you usually add salt to your food? |Do you experience anal irritation? |
|Do you have more than 2 alcoholic drinks a day? |Do you have a bowel movement daily? |
|Is there a history of heart disease in your family? |Do your stools float? |
| | |
|Exercise Profile |Immune Profile |
|Do you take exercise that noticeably raises your |Do you get more than three colds a year? |
|Heart beat for 20 minutes more than 3 times a week? |Do you find it hard to shift an infection (cold or otherwise)? Are you prone |
|Does your job involve vigorous activity? |to thrush? |
|Do you regularly play a sport? (Football, squash, etc.) |Are you prone to cystitis? |
|Do you have any physically tiring hobbies? (Gardening, etc.) Do you |Do you often take antibiotics more than twice a year? |
|consider yourself fit? |Is there a history of cancer in your family? |
| |Have you ever had any growths or lumps biopsied? |
|Pollution Risk Profile? |Do you have an inflammatory disease such as eczema, asthma or arthritis? |
|Do you live in a city or by a busy road? |Which? |
|Do you spend more than 2 hours a week in traffic? |Do you suffer from hay fever? |
|Do you exercise (jog, cycle, play sports) by busy roads? |Do you suffer from allergy problems? |
|Do you smoke more than 5 cigarettes a day? |Have you had a major personal loss in the last year? |
|Do you live or work in a smoky atmosphere? | |
|Do you buy foods exposed to exhaust fumes? |Histamine Profile |
|Do you generally eat non-organic produce? |Underline the following that apply to you: |
|Do you drink more than I unit or oz of alcohol a day? (I glass of |Sleep over 8 hours, little sex drive, much body hair, infrequent colds, |
|wine, I pint of beer, or I measure of spirits) |sluggish metabolism, slow to wake up, short toes and fingers, suspicious by |
|Do you spend a lot of time in front of a TV or VDU? |nature, fat or 'well covered', can tolerate pain. Sleep less than 7 hours, |
|Do you usually drink unfiltered tap water? |strong sex drive, little body hair, family history of allergies, fast |
| |metabolism, 'morning person', long toes and fingers, tends towards depression;|
|Stress Profile |don't put on weight, poor tolerance of pain. |
|Is your energy less now than it used to be? | |
|Do you feel guilty when relaxing? |Allergy Profile |
|Do you have a persistent need for achievement? |Do you suffer from any of the following? Please underline. |
|Are you unclear about your goals in life? |Nasal problems, hay fever, eczema, dermatitis, asthma, migraine, irritable |
|Are you especially competitive? |bowel syndrome, frequent bloated-ness, facial puffiness. Do you have any |
|Do you work harder than most people? |allergies?- If so what? |
|Do you easily become angry? |State type of reaction? |
|Do you often do 2 or 3 tasks simultaneously? |Have they been tested? |
|Do you get impatient if people or things hold you up? |What food or drinks would you find hard to give up? |
|Do you have difficulty getting to sleep? | |
| |QUESTIONS FOR WOMEN ONLY |
|Glucose Tolerance Profile |Are you pregnant? If so how many weeks? |
|Do you need more than 8 hours sleep a night? |Are you trying to become pregnant? |
|Are you slow to wake in the morning? |If so how long have you been trying? |
|Do you need something to get you going in the morning, like a tea, |Have you ever had a miscarriage? |
|coffee or cigarette? |If so at how many weeks did you miscarry? |
|Do you have tea, coffee, food and drinks with sugar, or cigarettes, at|Do you have an IUD fitted? |
|regular intervals during the day? |Or use a birth control pill? |
|Do you often feel drowsy during the day? |Do you have regular periods? |
|Do you get dizzy or irritable if you don't eat often? |Are you post menopausal? |
|Do you avoid exercise due to tiredness? |Do you suffer from pre-menstrual bloated-ness, tiredness, irritability, |
|Do you sweat a lot or get excessively thirsty? |depression, breast tenderness, headaches (please underline) |
|Do you sometimes lose concentration? | |
|Is your energy less now than it used to be? | |
DIET ANALYSIS
Please underline, BOLD or highlight all that apply the questions to which you would answer 'yes' and fill in the 'number of times' per week you eat or drink the food referred to in the question.
I. - Were you breast-fed?
2. - Was a significant percentage of your diet as a child high in fatty foods and sugar?
3. - Do you go out of your way to avoid foods containing preservatives or additives?
4. - Do you avoid foods that contain sugar?
5. - How many teaspoons of sugar do you add to food/drinks each day?
6. - Do you use salt in your cooking?
7. - Do you add salt to your food?
8. - How many coffees do you drink each day?
9. - How many cups of tea do you drink each day?
10. - How many times a week do you have meals containing fried food?
11. - How many packets of 'instant' or fast foods do you eat each week?
12. - How many times a week do you eat chocolate or confectionery?
13. - What percentage of your diet is raw fruit and raw vegetables?
14. - Do you wash fruit and vegetables before eating?
15. - Do you normally eat white rice or flour?
16. - How many cans of food do you eat per week?
17. - How many slices of bread or rolls do you eat each week?
18. - How many pints of milk do you drink in a week?
19. - How many times a week do you eat red meat? (Beef, pork, Iamb or game)
20. - How many times a week do you eat white meat? (Poultry, fish)
21. - What is your usual alcoholic drink?
22. - How many glasses do you drink a week?
23. - How many times a week do you eat live yoghurt?
24. - Do you use a water filter or drink bottled water instead of tap water?
25. - Do you frequently eat under stressful conditions or on the move?
26. - Does your job involve eating out a lot?
27. - How would you describe your appetite?
a) Poor b) Average c) Good d) Ravenous e) Fluctuating
Food Diary
Write down all the foods and drinks consumed over the next three days, starting today using the enclosed form. Please add as much information as possible including quantities eaten, brand names, and whether the food is fresh or packaged, refined or natural. Also your mood or how you feel at the time.
Extra Information
If you have any recent blood test results from your doctor or other information that may be of use to your nutritionist please enclose them or bring them along to your consultation. NHS GP’s will generally allow you to have copies of your notes for a 30p fee to cover photocopying.
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Yvonne Bishop-Weston BSc Dip ION MBANT
Tel: 0871 2884642 Fax: 08712884643
Text: 07988897759
Email clinic@.uk
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Personal Program for Optimal Health
Your Name …
This questionnaire is designed to provide your nutritionist with all the information necessary to build you an individual nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.
Each question in this section starts with a list of symptoms associated with nutritional deficiency. Please underline, BOLD or Highlight the conditions you often suffer from. Some symptoms are repeated.
Please HIGHLIGHT them in every instance.
Please return forms ASAP PLEASE NOTE THIS IS ADMIN NOT THE CLINIC ADDRESS
And enclose payment to confirm appointment (Cheques payable to Foodsfor Life) or pay online
Foods For Life, Exmouth Cottages, 31 Eland Road, Croydon CR0 4LJ Web london-nutritionist.co.uk
Tel:0871 2884642 Text 07944 068 432 Email to : clinic@foodsforlife.co.uk
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