NCT Nutrition



NCT Nutrition

PRE CONSULTATION QUESTIONAIRE

Please write clearly and answer the questions as accurately as possible as this will help your treatment. All information given will be treated as strictly confidential.

GENERAL INFORMATION

|Date questionnaire completed |

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|Name |Title |

|Address | |

| |Tel. no. |

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| |Mobile |

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| |E-mail |

|Marital Status |Date of Birth Age |

| |Number of children, their ages and gender: |

|Occupation | |

|Height |Weight |

|Blood group, if known |Blood pressure, if known |

|Are you currently planning to become a parent? Pregnant? Or experiencing fertility problems? |

|Permission to contact your medical doctor? |Doctor’s name & address |

|Yes / no | |

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| |Tel. no. |

|Does your doctor know that you plan to see a Nutritional | |

|Therapist? Yes / no | |

GOALS

|Which aspects of your health would you most like to improve? |

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HEALTH/SYMPTOM SCREEN

|If you have problems in any of the areas below, please rate the severity of the symptoms by marking the appropriate box next to the|

|symptom where; |

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|1 = Mild 2 = Moderate 3 = Severe |

|DIGESTIVE TRACT |

|If yes, have you received any conventional treatment/medication/ tests? |

|Have you taken any antibiotics recently? |

|Please give details of all current medication |

|Medication |Dose |Start date |Any side effects |

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ALTERNATIVE COMPLIMENTARY THERAPY

|Please give details of any other therapy you have sought: |

|Please list any remedies (e.g. herbal/homeopathic etc.) or nutritional supplements that you take: |

|Remedy/supplement |Dose |Start date |Any side effects |

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PLEASE BRING ANY SUPPLEMENTS / REMEDIES TO YOUR CONSULTATION

MEDICAL HISTORY

|Please list your illnesses/operations (excluding colds & flu) starting from your childhood and including any current problems |

|Illness/operation |Age of onset |Duration |Medication/treatment |

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TRAVEL

|Have you been abroad in the last 5 years? Please specify where: |

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|Have you suffered from digestive illnesses/problems either whilst abroad or after returning from abroad? |

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FAMILY MEDICAL HISTORY

|What, if any, illnesses are present on your mother’s/father’s side of the family? |

|(E.g. heart disease/cancer/allergies etc.) |

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|If you have any siblings, do they have any illnesses/conditions? |

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DIETARY HABITS

|Is your diet based on any religious, personal, medical or other | |

|choice (e.g. Hindu, Muslim, vegetarian, vegan, gluten-free etc)? | |

|Please specify | |

|Do you have any special dietary requirements? Please specify | |

|Have you been on/are currently on any specific diets? Please | |

|specify / give duration? | |

|How many times a week do you consume ready meals? | |

|How often do you cook at home? | |

|Do you regularly miss meals? | |

|List your favourite foods | |

|Are there any foods that you would find hard to give up? | |

|Do you crave any particular foods? | |

|Are there any foods or drink that cause your symptoms to worsen? | |

TYPICAL FOOD CONSUMPTION

|How many portions of vegetable/salad (excluding potatoes) do you | |

|typically eat each day? | |

|How many portions of fruit (including dried fruit and fruit | |

|juice) do you typically eat each day? | |

|How many portions of carbohydrate do you typically eat each day? | |

|(Cereals, bread, pasta, rice and potatoes) | |

|How often do you eat red meat? (Beef, lamb & pork) | |

|How often do you eat processed meat? (Bacon, ham, sausage, | |

|salami) | |

|How often do you eat fish? | |

|How often do you eat cheese, cream, butter and yoghurt? | |

|How much cow’s milk do you consume? | |

|How often do you eat chocolate or confectionary? | |

|How often do you eat snack foods (crisps, salted nuts etc.? | |

|How much water do you drink daily? | |

|How much tea and coffee do you drink daily? | |

3-DAY FOOD DIARY

In order to gain maximum benefit from your consultation, please write down exactly what you ate & drank. Please try to pick typical days.

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|How much |Food type |Time |Where |Alone/with whom |Activity |Mood |

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MOTIVATION

|How motivated are you to change the way you eat and experiment with new foods? |

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|I will try anything that might improve my condition |

|I feel I can cope with a moderate amount of change |

|I feel very anxious about changing my diet |

LIFESTYLE

|How many units of ALCOHOL|Per day? |Per week? |Per weekend? |1 pint of lager/beer = 2 units |

|do you usually drink: | | | |1 glass of wine = 2 units |

| | | | |1 pub measure of spirits = 1 unit |

|What do you drink? |Beer/lager |Wine |Spirits |Other |

|How would you best describe your drinking habits? |

|Minimal social |Small amounts frequently |Large amounts infrequently |Large amounts frequently |

|Do you take regular EXERCISE? Please specify: |Would you describe yourself as: |

| |VERY ACTIVE |

| |ACTIVE |

| |MODERATELY ACTIVE |

| |SEDENTARY |

|Do you SMOKE? Y/N |If you have stopped smoking when did you give up? |

|If so how many per day? | |

|On a scale of 1-10 with 10 being the highest, how would you rate your current stress levels? |

|Are there any issues that make you feel STRESSED at the moment/ e.g. major life change (new job, parenthood, moving house, becoming|

|a parent) |

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|Do you have a difficult time getting to |Do you wake up in the night? |How many hours sleep do you usually get? |

|sleep? | | |

|Do you find it hard to get up in the |Do you find it hard to relax? |Do you feel rushed/edgy most of the time? |

|morning? | | |

|What do you do to relax? |

|Are your symptoms affecting any activities, such as socialising, driving, housework? |

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|Is there any other information relating to your condition, which you think may be important? |

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DISCLAIMER

I understand that Nutritional Therapy is not a substitute for professional medical treatment and that the Nutritional Therapist does not diagnose medical conditions, but may help manage them through diet and the use of supplements. Therefore I accept that Sharon Schroeter has my permission to contact my medical doctor if she deems it necessary and beneficial for me (The patient).

I accept the Conditions of the Disclaimer (please sign)…………………………....Date………………

Please return completed & signed questionnaire and your completed food diary to Sharon Schroeter, 7D Stirling Avenue, Buccleuch, Sandton, 2090 or email to schroeter.sharon@

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