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NUTRITIONAL THERAPYPRE-CONSULTATION QUESTIONNAIREPRIVATE AND CONFIDENTIALThis questionnaire is designed to provide me with much of the information necessary to design your personalised Nutritional Therapy Programme, which will be tailored to suit your own unique needs. Please answer all questions as fully and accurately as possible.SECTION 1: GENERAL INFORMATIONNAMEADDRESSTELEPHONE NUMBEREMAIL ADDRESSDATE OF BIRTHGENDERHEIGHTWEIGHTMEASUREMENTSWAIST (TO BE MEASURED AT NAVEL LEVEL):HIP (MEASURE AT WIDEST AREA OF HIPS):CHEST (MEASURE DIRECTLY ACROSS NIPPLE LINE):UPPER ARM (RIGHT): MEASURE 7 INCHES DOWN FROM TIP OF SHOULDER: UPPER ARM (LEFT): MEASURE 7 INCHES DOWN FROM TIP OF SHOULDER:UPPER THIGH (RIGHT): MEASURE AT WIDEST POINT:UPPER THIGH (LEFT): MEASURE AT WIDEST POINT:OCCUPATIONBLOOD PRESSURE ( IF KNOWN)CHOLESTEROL LEVEL (IF KNOWN)ANY OTHER MEDICAL TEST RESULTS?DOCTORS NAME AND ADDRESSDOCTORS TELEPHONE NUMBERDO I HAVE YOUR PERMISSION TO CONTACT YOUR DOCTOR?SECTION 2: EXERCISEDO YOU DO ANY EXERCISE?IF YES, WHAT TYPE AND HOW OFTEN?SECTION 3: HEALTH PROFILEWHAT ARE THE MAIN REASONS FOR THIS CONSULTATION? PLEASE GIVE DETAILS OF WHEN THESE PROBLEMS STARTED AND HOW THEY CAME ABOUT IF KNOWN. 1.2.3.4.5.UNDER WHAT CIRCUMSTANCES DO THESE PROBLEMS IMPROVE?UNDER WHAT CIRCUMSTANCES DO THEY GET WORSE?DO YOU TAKE ANY MEDICATION FOR THEM? PLEASE STATE THE DOSAGE AND FREQUENCY.1.2.3.4.5.HOW AS YOUR HEALTH BEEN OVER THE LAST YEAR? PLEASE DETAIL ALL HEALTH RELATED ISSUES, HOWEVER MINOR THEY MAY SEEM, ALONG WITH ANY MEDICATION YOU HAVE TAKEN.SECTION 4: COMPLEMENTARY THERAPIESPLEASE GIVE DETAILS OF ANY COMPLEMENTARY THERAPIES YOU HAVE SOUGHT. PLEASE LIST ALL REMEDIES/SUPPLEMENTS INCLUDING DOSAGES.REMEDY DOSE START DATE END DATESECTION 5: MEDICAL HISTORY PROFILEPRE-SCHOOL YEARSWERE YOU BREASTFED? IF SO, HOW LONG FOR?WHAT AGE WAS YOUR MOTHER WHEN SHE GAVE BIRTH TO YOU?DID YOU HAVE ALL THE USUAL CHILDHOOD ILLNESSES, SUCH AS MEASLES, CHICKEN POX AND MUMPS?DID YOU HAVE ALL THE USUAL CHILDHOOD IMMUNIZATIONS?DO YOU KNOW OF ANY OTHER ILLNESSES YOU HAD AS A SMALL CHILD?PLEASE DETAIL ALL KNOWN MEDICATIONS TAKEN AS A SMALL CHILD:SCHOOL AND TEENAGE YEARSPLEASE GIVE DETAILS OF ANY ILLNESSES/HEALTH CONCERNS, INCLUDING AGE WHEN THESE OCCURRED, INCLUDING ANY MEDICATIONS TAKEN.SECTION 6: QUESTIONS FOR FEMALE CLIENTS ONLYMENSTRUATIONWHAT AGE WERE YOU WHEN YOU STARTED YOUR PERIODS?ARE YOU PRE OR POST MENOPAUSAL?IF POST MENOPAUSAL, WHAT AGE DID YOU START THE MENOPAUSE?ARE/WERE YOUR PERIODS REGULAR?IF SO, HOW MANY DAYS BETWEEN THE BEGINNING OF ONE AND THE BEGINNING OF THE NEXT?DO YOU/DID YOU EVER REGULARLY HAVE MISSED PERIODS?ARE THEY/WERE THEY PAINFUL?DO YOU/ DID YOU TAKE MEDICATIONS TO RELIEVE PERIOD PAIN? IF SO, WHAT MEDICATIONS?ARE/WERE YOUR PERIODS HEAVY/LIGHT?HOW LONG DO/DID THEY LAST FOR?DO YOU/DID YOU EVER SUFFER FROM PMT?SECTION 7: MAIN MEDICAL LIFE HISTORYPLEASE GIVE AS MUCH DETAIL AS POSSIBLE ABOUT ALL HEALTH RELATED MATTERS WHICH HAVE OCCURRED THROUGHOUT THE COURSE OF THE REST OF YOUR LIFE. PLEASE INCLUDE ALL MEDICATIONS TAKEN.HAVE YOU EVER HAD ANY OPERATIONS? PLEASE GIVE DETAILS.HAVE YOU EVER HAD ANY CHILDREN? PLEASE GIVE DETAILS OF HOW THE BIRTHS WERE.DO YOU TAKE/HAVE YOU EVER TAKEN THE CONTRACEPTIVE PILL? IF SO, HOW LONG FOR?DO YOU HAVE ANY ALLERGIES? PLEASE GIVE DETAILS OF WHETHER OR NOT YOU’VE ALWAYS HAD THESE ALLERGIES AND IF NOT, WHEN DID THEY DEVELOP?DO YOU CATCH COLDS/FLUS EASILY, OR NOT VERY OFTEN?DO YOU HAVE/HAVE YOU EVER HAD ANY SKIN PROBLEMS? IF SO, PLEASE GIVE DETAILS.ARE YOU TAKING ANY MEDICATIONS AT PRESENT? PLEASE LIST.SECTION 8: FAMILY MEDICAL HISTORYPLEASE GIVE DETAILS OF ANY MAJOR ILLNESSES/HEALTH RELATED CONCERNS OF THE FOLLOWING FAMILY MEMBERS.FATHER:MOTHER:SIBLINGS:GRANDPARENTS:SECTION 9: DIGESTIVE PROFILEDO YOU CHEW YOUR FOOD THOROUGHLY?DO YOU SUFFER FROM BAD BREATH?ARE YOU PRONE TO STOMACH UPSETS?DO YOU FIND IT DIFFICULT DIGESTING FATTY FOODS?DO YOU SUFFER FROM FLATULENCE, BURPING OR BLOATING?DO YOU HAVE A BOWEL MOVEMENT DAILY?DO YOU SUFFER FROM DIARRHOEA OR CONSTIPATION?WHAT IS YOUR APPETITE LIKE?SECTION 10: RESPIRATORY FUNCTIONDO YOU EVER SUFFER FROM WHEEZING, ASTHMA, SHORTNESS OF BREATH OR DIFFICULTY BREATHING? PLEASE GIVE DETAILS.SECTION 11: SLEEP PATTERNSDO YOU FALL ASLEEP EASILY?HOW MUCH SLEEP YOU NEED? DO YOU SLEEP THROUGHOUT THE WHOLE NIGHT?DO YOU WAKE UP FEELING REFRESHED/TIRED?SECTION 12: LIFESTYLEHOW ARE YOUR ENERGY LEVELS? IF YOU GET TIRED, IS THERE A CERTAIN TIME OF DAY YOU FEEL MORE TIRED?DO YOU SMOKE? IF SO, HOW MANY CIGARETTES/DAY?HOW MUCH ALCOHOL DO YOU DRINK PER WEEK, ON AVERAGE?DO YOU DRINK ABOUT THE SAME AMOUNT MOST DAYS OR IS THIS AMOUNT DRUNK OVER JUST ONE OR TWO DAYS?DO YOU REGULARLY MISS MEALS?SECTION 13: MIND, MOOD AND EMOTIONSDO YOU HAVE A STRESSFUL LIFESTYLE?IS THERE ANYTHING MAKING YOU FEEL STRESSED AT THE MOMENT?DO YOU EVER FEEL LOW, OR DEPRESSED?DO YOU EVER HAVE ANY MOOD SWINGS?HOW IS YOUR CONCENTRATION?HOW IS YOUR MEMORY?SECTION 14: OTHERARE YOU EVER EXCESSIVELY THIRSTY?DO YOU SUFFER FROM FREQUENT OR URGENT URINATION?HOW IS YOUR TASTE AND SMELL?DO YOU HAVE ANY MERCURY DENTAL FILLINGS? HOW MANY?DO YOU USE A LOT OF HOUSEHOLD CLEANING PRODUCTS?SECTION 15: ANY OTHER RELEVANT INFORMATIONPLEASE GIVE ANY OTHER DETAILS WHICH YOU FEEL MAY BE RELEVANT. Copyright of Tai Chi and Nutrition for Health and Wellness, ................
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