PRIVATE AND CONFIDENTIAL



PRIVATE AND CONFIDENTIALHealth QuestionnairePlease provide information as fully and accurately as possible. If at any time you need more space please continue on a separate sheet.784796557594578428855746757842885574675Title ........ First Name .................................................................Last Name …………………..........Address .....................Email.........................................................Telephone Numbers………………… NRIC/FIN/Passport No:………………………Occupation ..................................................................Date of Birth …………………….............................Height (without shoes).....Weight (without clothes):......Waist circumference.......Blood group (if known)....Blood pressure.... Resting pulse rate.... Your weight is stable (please underline) increasing decreasingHip circumference:Childhood immunisations: yes/no(please underline)Health profileWhat outcomes are you hoping to achieve? ...Please list all the health issues you would like to focus on. Continue on a separate sheet if you need more space.Health Issue (e.g. eczema)Frequency (e.g. 4 times a week)Onset dateSeverity (mild, moderate, severe)What makes you feel better(e.g. rest) What makes you feel worse(e.g. wheat)Have you had any recent health tests? Please specify or attach results.............Please specify if you suspect your symptoms relate to a particular event/time in your life........Please give details if you have had any head injuries, surgeries, biopsies, other diagnosed medical conditions, significant periods of ill health or suffer from any chronic or niggling health issues (e.g. high blood pressure, frequent colds, recurrent urinary infections, etc). (attach separate sheet if necessary)....Medication & Remedies: please list anything you take regularly including prescribed medications, self-prescribed remedies, nutritional supplements, herbal or homeopathic remedies. Continue on separate page if necessary.Medication/RemedyDoseCondition being treatedFrequency & DurationAntibiotic history: please state when and why you last took antibiotics plus any previous times you can remember:Body CheckPlease UNDERLINE or HIGHLIGHT any conditions that you regularly experience in past 6 monthsHeadheadaches, migraine, stiff neck, fuzzy headed, dizziness, poor balance, pounding head, feeling of hangover, seizures, unexplained pain, Hairoily, dry, poor condition, brittle, thinning, prematurely grey, dandruff, increased facial hair, increased body hair, decreased body hairMouth/Throatsore tongue, coated tongue, teeth problems, mouth ulcers, bad breath, sore throats, poor sense of taste, excess saliva, dry mouth, difficulty swallowing, hoarse voice, gingivitis, bleeding gums, cold sores, metallic taste in mouth, cracked lips/corners, mucus, tonsillitis, enlarged glands, teeth grinding, jaw problemsEyesburning, gritty, protruding, prone to infection, sticky, crusting, itchy, painful, poor night vision, dry, pain, cataracts, sensitive to light, bags, swollen eyelids, eyelids twitch, blurred vision, double vision, failing eyesight, yellowish, dark circles under eyes, floaters, bright flashes, halo around lightEarsblocked, ache, itchy, weeping, watery, overly waxy, creased earlobe, ringing, deafness, sensitive to loud noise, hearing lossNosestuffy, congested, runny, frequent nose bleeds, sinusitis, prone to snoring, hayfever, post-nasal drip, rhinitis, sneezing, poor sense of smell, polypsMusclestender, sore, cramps, spasms, twitches, loss of tone, wasting, weak, stiff, frozen, numbnessSkindry, rough, flaky, scaly, puffy, pale, brown patches, change in moles or lesions, prematurely lined, congested, oily, clammy, yellow, small bumps on upper arm, vitiligoSkin prone toacne, pimples, rosacea, dermatitis, psoriasis, rashes, boils, hives, itching, stretch marks, cellulite, easy bruising, tread veins, varicose veins, ringworm, allergic reactions, excessive sweatingJoints (fingers, knees, back, shoulders, etc)Painful, inflamed, swollen, stiff, rheumatic, arthritic, aching, sore, difficulty bending, reduced mobility, unsteadiness, slow movement, pain in mid-backMood(underline your predominant states even if they conflict) depressed, anxious, tense, angry, happy, balanced, optimistic, sad, pessimistic, tired, can’t be bothered, hyperactive, cheerful, agitated, easily upset, aggressive, pent, up, tearful, jittery, frightened, explosive, worried, annoyed, overwhelmed, suicidal, fluctuating, Mindforgetful, difficulty learning new things, easily confused, difficulty concentrating, easily frustrated, easily distracted, phobias, paranoia, panic attacks, difficult to make decisions, can’t switch off, loss of interest in daily life, fogginess, dyslexia, dyspraxia, hyperactive, no motivation, visual hallucinationsChestfrequent colds and chest infections, asthma, bronchitis, diagnosed heart condition, chest discomfort/pain, short of breath, difficulty breathing, wheezing, persistent cough, noisy breathing, palpitations, irregular heartbeatGutbloated, tender, cramping, distended, nausea, vomiting, belching, sensation of fullness, acid reflux, heartburn, flatulence, churning, painful, irritable bowel syndrome, coeliac, hiatus hernia, diverticula, polyps, haemorrhoids, ulcers, sluggish, sensitive, constipation, diarrhoea, fissuresGenitalsitchy, cystitis, thrush, ulcers, warts, herpes, groin pain, prostatitis, pelvic inflammatory disease, impotence, painful intercourse, vaginal dryness, painful or frequent urination, urinary incontinence, unexplained dischargeHandsdry, cracked, eczema, sore joints, puffy, cold, chilblains, numbness, tingling, shaking or tremor, feel clumsy and uncoordinated, poor circulationNailsfragile, dry, brittle, flaky, peeling, splitting, hang nails (split cuticles), ridged, spoon shaped, pitted, curved up, white spots on more than 2 nails, horizontal white lines, thickened dark nails, pale nail bed, infectedLegs & Feet‘restless legs’, swollen, aching, athlete’s foot, fungal nails, burning feet, tender heels, gout, sciatica, cold feet, tingling, numb, prickling, cracking heelsImportant Symptoms:Please underline if you suffer from any of the following symptoms which may require additional medical care:persistent or unexplained pain, unexplained bleeding or discharge from nipple, vagina or rectum, blood in sputum, vomit, urine, stools; breast lumps, calf swelling, difficulty swallowing, excessive thirst, increased urination, inability to gain or lose weight, loss of appetite, paralysis, slurred speech, unexplained bruising, rash or weight loss, black tarry stools, painless ulcers or fissures, bleeding in pregnancyYour family historyIf you have a family history of disease or allergies (e.g. heart disease, asthma, diabetes, etc), please state disease, age at onset, gender.Grandparents: Parents:Siblings:Children:Your daily life______ Do you enjoy your daily life?______ How many people depend on your support?______ Do you feel supported by people around you?______ Are you recently separated/divorced/a new parent?______ Have you lost someone close to you recently?______ Have you moved house or changed job recently?______ Do you work long or irregular hours?______ Is your workload bigger than you can manage?______ Do you worry over little things?______ Are you under significant stress in any other way?______ Do you feel guilty when you are relaxing?______ Do you have a strong drive for achievement/______ Do you often do 2 or 3 tasks simultaneously?______ Do you take regular exercise?______ Is your job active?______ Do you have any active hobbies?______ Do you sleep well?______ What do you do for relaxation?______ How important is religion or spirituality for you and your family’s life?Your energy levels______ Do you need more than 8 hours sleep per night?______ Is your energy less than you want it to be?______ Do you find it difficult to get going in the morning?______ Do you feel drowsy during the day?______ What time(s) of day is your energy lowest______ Do you get dizzy or irritable if you don’t eat often?______ Do you use caffeine, sugar or nicotine to keep going?______ Do you find it difficult to concentrate?______ Do you feel dizzy or light-headed if you stand up quickly?______ Do you suffer from unexplained fatigue or listlessness?______ Do you feel unusually fatigued after exercise?Your digestion Do you regularly experience...______ Indigestion (after food or between meals?) ______ Indigestion after fatty food? ______ Bowel movement shortly after eating? ______ Frequent stomach upsets or stomach pains? ______ Nausea or vomiting? ______ Pain between the shoulders or under the ribs? ______ Constipation or hard-to-pass stools? ______ Diarrhoea or ‘urgency to go’? ______ Blood or mucus in stools? ______ Undigested food in stools?______ Generally inconsistent bowel movements?______ Anal itching?______ Thrush or cystitis?______ How many bowel movements do you have in 24 hours?______ Have you noticed any recent change in bowel habit?______ Are your stools pale, mid-brown, dark brown, black or grey? ______ Have you ever had a stomach upset after foreign travel?______ Do any foods cause digestive problems? Which ones?Your toxic exposure______ Do you live, exercise or work in a city or by a busy road?______ Do you spend a lot on time on busy roads?______ Do you live close to an agricultural area?______ Do you have any pets?______ Do you drink unfiltered water?______ How many units, if any, of alcohol do you drink a week?______ What is your usual alcoholic drink?______ How many cigarettes, if any, do you smoke a day?______ If an ex-smoker, how many years did you smoke?______ Do you live in a smoky environment?______ Do you think you may be addicted to anything?______ Do you spend a lot of time in front of a TV or computer?______ Do you spend a lot of time on a mobile phone?______ Do you sunbathe a lot?______ Are you a frequent flyer?______ Are you exposed to chemicals through work or hobby?______ Do you heat, freeze or wrap food in plastics?______ Do you cook or wrap food in aluminium?______ Do you regularly take antacid (indigestion) medication?______ Roughly what percentage of your food is organic?______ Do you frequently fry or roast food at high temperature?______ Do you regularly eat browned or barbequed food?______ Do you eat oily fish or shellfish more than 3x a week?______ Do you regularly consume artificial sweeteners?______ Do you floss your teeth regularly?______ Are you have mercury amalgams or root canals? ______ Do you have dental or breast implants or joint replacements (e.g. hip, knee)?Women only______ If you are pregnant, how many weeks?______ Are you trying to become pregnant?______ Are you breast-feeding at present?______ How many children have you had?______ Have you had problems with fertility?______ Have you ever had a miscarriage?______ What contraception, if any, do you use?______ Menstruating women- are your periods regular?______ Are you or have you been on HRT?______ Do you have bleeding/spotting in between periods?______ Are your periods particularly heavy or painful?______ Do you suffer from PCOS, fibroids, endometriosis, ovarian cysts?______ Have you had any known genitor-urinary conditions?______ Do you suffer from fibrocystic breasts?______ Was your last PAP smear normal?______ Are you happy with your sex drive?______ Menopausal women, please state age of menopauseMenstruating women: please underline if you experience: pre-menstrual bloating, tiredness, irritability, depression, breast tenderness, water retention, headaches. Others please state:_________Menopausal women: please underline if you suffer from:hot flushes, insomnia, osteoporosis, mood swings, depression, vaginal dryness. Others please state: _______Men only_____ Do you experience mood swings or depression?_____ Loss of sex drive?_____ Loss of motivation and drive?_____ Have you had any known genitor-urinary conditions?_____ Have you had fertility problems?_____ Do you have problems achieving or maintaining an erection?_____ Do you have frequent or difficult urination?_____ Do you suffer from prostate problems?_____ Do you wake at night to urinate?_____ Is it difficult for you to start or stop urine stream?_____ Do you feel pain or burning when urinating?_____ Do you have hernia?_____ Do you experience genital pain?Eating habitsWhat are your favourite foods? What foods do you dislike?What foods do you crave?What foods would you find hard to give up?What foods, if any, do you suspect do not agree with you?If you have eating binges, what do you binge on?______ Do you cater for a special diet in the household?______ Who does the cooking in your household?______ Do you avoid any food for cultural/ethical reasons?______ Have you recently changed your diet?______ Do you ‘go on diet’ often to control weight?______ Do you eat on the move or when stressed?______ Have you ever suffered from an eating disorder?______ Do you chew your food thoroughly?______ Are you excessively thirsty?Please complete the separate chronological history and food and lifestyle diary.Healthcare ProvidersIs this your first visit to a Functional Medicine Practitioner/Nutritional Therapist?How did you find out about me?GP’s Name:Address:Telephone:Are there any other therapists/clinics involved in your care? Please list:I have disclosed all the relevant information applicable to this consultation and my health status at this point in time. I consent for the information provided to be used by my Nutritional Therapist and for her to liaise with appropriate health professionals.Signed:Date: Chronological HistoryPlease list to the best of your recollection any significant life event, ill health and stress (emotional, mental) during the following time frames. E.g. Mother’s pregnancy – preeclampsia, age 2 eczema, age 5 measles, age 10 parents divorce sad, confused, age 12 start of menses, v heavy, painful, age 19 university overseas, weight gain, age 23 job v stressful, relationship breakup, age 24 chronic fatigue, IBS, age 30 got married, age 31-32 tried to get pregnant, not successful, age 34 IVF, son born caesarian, age 40 diagnosed hypothyroid, brain fog, depressed, age 49 early menopause, hot flashes, hair loss…Time FrameSignificant events, health issues, forms of stressPrebirth birth - mother’s pregnancy0-2 years old3-7 years old8-10 years old11-19 years old20-30 years old31-40 years old41-50 years old51-60 years old61 years onwards3 Day Food & Lifestyle DiaryName: Date:Please choose 2 fairly typical weekdays and a weekend or a ‘day off’. Record as much as you can about your eating, exercise, sleeping and leisure patterns. Please give as much detail as possible-home cooked, fresh, packaged, whole, refined, organic, amount, brands, etc. Your Diet – please record your food intake across 2 work or week days and 1 weekend/day off Your Routine – please do the same for your routineWeekday 1Weekday 2Day OffBreakfastTime:Time:Time:LunchTime:Time:Time:DinnerTime:Time:Time:SnacksTime:Time:Time:Drinks____ coffees (____ sugars/cup)____ ‘normal’ tea (____ sugars/cup)____ green/herbal tea____ fizzy drinks/cordial____ units/glasses of alcohol____ glasses of water____ other drinks____ coffees (____ sugars/cup)____ ‘normal’ tea (____ sugars/cup)____ green/herbal tea____ fizzy drinks/cordial____ units/glasses of alcohol____ glasses of water____ other drinks____ coffees (____ sugars/cup)____ ‘normal’ tea (____ sugars/cup)____ green/herbal tea____ fizzy drinks/cordial____ units/glasses of alcohol____ glasses of water____ other drinksDay 1Day 2Day 3Wake up timeGet up timeWork day start timeWork day breaks (total hrs)Work day end timeTime spent travellingTime spent exercisingType of exerciseExercise time of dayTime spent relaxingType of relaxationOther leisure activityOther routineEnergy low timesOverall moodGo to bed timeFall asleep timeUninterrupted sleep? Y/NY/NY/N ................
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