PRIVATE AND CONFIDENTIAL



Abundant Energy Expert Showing you how to build more vitality, well-being and energy for life

Physical Questionnaire

This questionnaire is designed to provide your practitioner with all the information necessary to build you an individual programme specifically tailored to your needs. Please answer all of the questions as accurately as you can. PRIVATE AND CONFIDENTIAL

|First name:       |Last name:       |

|Address:       |GP name and address:       |

|Name and contact details of your next of kin:       |Skype address:       |

|Marital Status:       |E-mail:       |

|Telephone number:       |Children, if yes state number:       |

|Occupation:       |Date of birth:       |

|Your weight (without clothes):       |Your height (without shoes):       |

Health Profile

|Have you been diagnosed with any diseases or conditions? | |Duration |

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|Do you have any other health conditions Please describe: Duration |

|1 |      | |      |

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|4 |      | |      |

|5 |      | |      |

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|What medication (drugs) are you currently taking prescribed by a medical doctor (include contraceptive medication)? (state daily dosage) |

|1 |      | |      |

|2 |      | |      |

|3 |      | |      |

|4 |      | |      |

|What operations if any have you had – please include what age you were at the time | |      |

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|Genetic Hereditary Profile |

|Do you have children, if so, do they have any particular illnesses they suffer |If you have any brothers or sisters, are there any particular illnesses they suffer|

|from?       |from?       |

|What illness is/was your father prone to?       |What illness is/was your mother prone to?       |

| |

|Preconception, Prenatal, Birth |

|What was your mother’s diet like before and during pregnancy?       |Were you breast fed, if so, for how long?       |

|How was your mother’s health during pregnancy – did she take any antibiotics?      |Did your mother have silver (mercury)fillings when she was pregnant with you?      |

|Where there any issues during birth and were you a full-term or premature baby? | |

|      | |

| |

|Childhood – 20 years old Physical History |

|Was your diet high in sugar and refined carbohydrates?       |Were you physically active as a child?       |

|Did you have a full set of vaccinations as a child?       |Were you normal weight for your height growing up?       |

|Did you have any mercury fillings?       |Did you live on or near a farm where pesticides could have been used?       |

|Did you have any hobbies which exposed you to chemicals such as painting, carpentry| |

|etc?       | |

|Please state in chronological order and at what age you suffered any health issues in the below boxes (including childhood illnesses such as colic, asthma, eczema, |

|tonsillitis, frequent infections, ear infections, polio, chicken pox, sinusitis, frequent colds, flu etc): |

|Health at 1-5 years old?       |Health at 10-15 years old?       |

|Health at 5-10 years old?       |Health at 15-20 years old?       |

| |

|Adult Physical Health History and Current Environment |

|Have you been a frequent flyer?       |Do you live or work in a high rise building?       |

|Do you have any hobbies or a job which exposes you to chemicals and pesticides such|Are you financially secure or struggling to pay bills and pay for treatment for |

|as working in a lab, farming, carpentry?       |your illness?       |

|Do you have animals (pets) in your house, if so, please state?       |Do you live in a house, flat or other accommodation – how old is the building? |

| |      |

|Have you had many X Rays?       |Have you spent time in hospital, if so state how long and what for?       |

|How many amalgam fillings do you have?       |Have you taken a lot of prescribed medication in the past such as antibiotics or |

| |NSAIDS, please state, what and for how long?       |

|Please state in chronological order and at what age you suffered any health issues in the below boxes. Please state what if any triggers caused the issue: |

|Health at 20-30 years old?       |Health at 50-60 years old?       |

|Health at 30-40 years old?       |Health at 60-70 years old?       |

|Health at 40-50 years old?       |Health at 70+ years old?       |

| |

|Illness history, triggers, diagnosis, progression |

|What was going on in your life running up to the time you first got ill?       |What were the triggers, if there were any (e.g. caught a bug on holiday, a tick |

| |bite, vaccination, giving birth, stressful life experience?)       |

|How long did it take you to get a diagnosis?       |What were your initial symptoms?       |

|How have the symptoms and illness changed or developed through the course of the |How would you say your illness is progressing now – constantly getting worse, |

|illness?       |better, fluctuating, boom and bust or unchanging?       |

Treatment History – Insert an ‘x’ for yes to any therapy you have already undertaken and describe if it helped, worsened, or made no difference to your illness

| |NLP/       | |Cranial Osteopathy       |

| |Amygdala Retraining      | |Neurofeedback       |

| |Mickel Therapy       | |Herbalist       |

| |EMDR       | |Homeopathy       |

| |CBT       | |Reflexology/Acupuncture/Reiki       |

| |Graded Exercise      | |Yoga/Meditation/Tai Chi       |

| |EFT       | |Massage       |

| |Hypnosis       | |Nutritional Therapist       |

| |Psychotherapy       | |Dietician       |

| |Psychiatry       | |Naturopath       |

| |Perrin Treatment       | |Spiritual Counselling/Energetic treatment       |

| |Lymphatic Drainage       | |Other Private Medical Doctor       |

| |Colonic Irrigation       | |Chiropractor       |

| |Juicing/Raw food/Fasting       | |Other       |

How many different doctors and/or health practitioners would you say you have been to see in total approximately, during the course of your illness?      

Stage of Illness

Please mark an ‘x” by one or more of the stages you feel apply to you:

| Crash - Substantial physical immobilisation - very little capacity to do anything, mostly house or bed-bound |

| Misery – Wired but tired - many symptoms are experienced |

| Adaption - You would not think you were ill – however if they go beyond your set of physical limitations and “over do it” you can experience a return of ALL symptoms |

| Reintegration - gradually gaining more health and energy and have less symptoms – however dips do happen, they are just less frequent, less deep and last for a |

|shorter period of time |

Treatment History – Food and Supplements

| |Name of the supplement or diet|Describe what happened i.e. nothing, reacted | |Name of the supplement or |Describe what happened i.e. nothing, reacted |

| |– tick if taken before or done|badly, and if so in what way / or did it help, | |diet – tick if taken |badly and if so in what way or did it help, and|

| |the diet |and if so, how? | |before or done the diet |if so, how? |

| |Anti-Candida Diet |      | |Phosphatadyl choline |      |

| |Blood Type Diet |      | |VegEPA |      |

| |Elimination/Food Intolerance |      | |Melatonin |      |

| |diet | | | | |

| |Metabolic Typing Diet |      | |Parasite cleanse |      |

| |Raw food diet |      | |Methylfolate |      |

| |Atkins Diet |      | |Zinc |      |

| |Food Combining diet |      | |Vitamin C |      |

| |B12 injections |      | |B vitamins |      |

| |Magnesium injections |      | |L Carnitine |      |

| |St John’s Wort |      | |Co enzyme Q 10 |      |

| |D ribose |      | |Siberian ginseng |      |

| |5HTP |      | |Milk thistle |      |

| |Probiotics (gut bacteria) |      | |Malic acid |      |

| |Digestive enzymes |      | |Vitamin D3 |      |

| |Oral magnesium |      | |Iodine |      |

| |Anti-fungals (not drugs) |      | |Rhodiola/Ashwa-gandha |      |

| |Protein powders (e.g. whey |      | |Iron |      |

| |protein) | | | | |

| |Green drinks (e.g. green |      | |Essential oils – omega 3 |      |

| |barley) | | |and/or 6 | |

| |High dosage anti-oxidants |      | |Co enzyme A |      |

| |Multi vitamin and mineral |      | |Adrenal glandular |      |

| |Liquid or multi minerals |      | |Thyroid Glandular |      |

Private laboratory history

Please include copies of the tests below if you have them and you are starting treatment on the nutrition side of the clinic. Please mark ‘x’ by the tests you have done.

| |Adrenal Stress Index Test | |Growth Hormone |

| |Comprehensive Stool Analysis Test | |Female hormone panel (oestrogen, progesterone etc) |

| |Mitochondrial function Testing | |Neurotoxin visual contrast test |

| |Red cell Glutathione | |Thyroid including TSH, T4, T3 and anti-bodies |

| |Red cell magnesium | |Leaky gut test |

| |Mercury r Toxin ChallengeCandir Candidaualt timarsstic | |Live blood analysis or bioterrain analysis |

| |igueor Heavy Metal Challenge Test | | |

| |HPU or Pyrroluria | |IgG Food Intolerance Testing |

| |Hair mineral analysis | |Candida Saliva Test |

| |Red cell minerals | |Serum vitamins |

| |Genetic Profiling (liver detox, methylation etc) | |Lymphocyte Sensitivity Testing |

| |Western Blot for Lyme’s disease | |Bacterial or Viral testing |

| |Amino Acid Testing | |Fatty Acid Testing |

Dietary Profile

| |

DIET ANALYSIS

Write down all the foods and drinks consumed over the next three days, starting today. Please add as much information as possible including brand names, and whether the food is fresh or packaged, refined or natural.

|Day 1 Please state the amount of foods | |Day 2 Please state the amount of foods |

|Breakfast | |Breakfast |

|      | |      |

|Lunch | |Lunch |

|      | |      |

|Dinner | |Dinner |

|      | |      |

|Snacks/Drinks | |Snacks/Drinks |

|      | |      |

|Day 3 Please state the amount of foods | |What nutritional supplements do you take daily on a regular basis? |

|Breakfast | |      |

|      | | |

|Lunch | | |

|      | | |

|Dinner | | |

|      | | |

|Snacks/Drinks | | |

|      | | |

| |

|I hereby confirm that this information is correct to the best of my knowledge and that I am not withholding any important information. I understand that neither a |

|nutritional therapist nor a bioenergetic practitioner is able to diagnose or treat medical conditions. Neither nutritional nor bioenergetic advice is intended to |

|replace the advice of medical doctors. The treatment is not a substitute for the medical treatment of a doctor but it can work to complement it. If you have a health |

|concern always contact your licensed medical practitioner first. |

|Date: |      |Signed: |      |

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