Helenmaxwellnutrition.co.uk
Nutritional Therapy Questionnaire: Title:First Name:Last Name:Address:Postcode:Tel:Email:DOB:Age:Occupation:Permission to contact GP if needed:YESNOWeight:Height:Blood pressure (if known):Resting pulse (if known):Waist circumference (if known):Hip circumference (if known):Health issuesPlease specify the main reason for seeking nutritional advice your main goals? ..........................................................................................................................................................................................................................................Current health concerns or symptoms in order of priority (please detail any current medical investigation e.g. scans/blood testsOnset or duration1.2.3.4.5.Any other health issues, historic surgeries, diagnosed medical conditions, allergies etc. which might be relevant. ………………………………………………………………………………………………………………………………………………………………………………………Medication and remedies – please list anything and everything you take regularly including: GP medications, self-prescribed medication, supplements, herbal or homeopathic remediesName (medication & supplements) Dose & frequency e.g. 5mg x 2Reason for takingDurationAntibiotic history: please state when and why you last took antibiotics and any other occasions you can remember.Family history of disease or allergies:Grandparents:Parents:Siblings:Children:Exercise (type, how long and how often):Body ScanHeadHeadache FORMCHECKBOX migraine FORMCHECKBOX stiff neck FORMCHECKBOX fuzzy head FORMCHECKBOX dizziness FORMCHECKBOX poor balance FORMCHECKBOX pounding head FORMCHECKBOX feeling of hangover FORMCHECKBOX pain FORMCHECKBOX HairOily FORMCHECKBOX dry FORMCHECKBOX poor condition FORMCHECKBOX brittle FORMCHECKBOX thinning FORMCHECKBOX prematurely grey FORMCHECKBOX dandruff FORMCHECKBOX increased facial hair FORMCHECKBOX increased body hair FORMCHECKBOX decreased body hairMouthSore tongue FORMCHECKBOX white/red patches FORMCHECKBOX tooth decay FORMCHECKBOX ulcers FORMCHECKBOX bad breath FORMCHECKBOX sore throats FORMCHECKBOX poor sense of taste FORMCHECKBOX excess saliva FORMCHECKBOX dry mouth FORMCHECKBOX difficulty swallowing FORMCHECKBOX hoarse voice FORMCHECKBOX gingivitis FORMCHECKBOX bleeding gums FORMCHECKBOX cold sores FORMCHECKBOX EyesBurning FORMCHECKBOX gritty FORMCHECKBOX protruding FORMCHECKBOX prone to infection FORMCHECKBOX sticky FORMCHECKBOX itchy FORMCHECKBOX painful FORMCHECKBOX poor night vision FORMCHECKBOX dry FORMCHECKBOX cataracts FORMCHECKBOX sensitive to light FORMCHECKBOX bags FORMCHECKBOX swollen eyelids FORMCHECKBOX blurred vision FORMCHECKBOX double vision FORMCHECKBOX failing eyesight FORMCHECKBOX EarsBlocked FORMCHECKBOX , sore FORMCHECKBOX , itchy FORMCHECKBOX , weeping FORMCHECKBOX , watery FORMCHECKBOX , overly waxy FORMCHECKBOX , creased earlobe FORMCHECKBOX NoseCongested FORMCHECKBOX runny FORMCHECKBOX frequent nose bleeds FORMCHECKBOX prone to snoring FORMCHECKBOX sinusitis FORMCHECKBOX hay fever FORMCHECKBOX post-nasal drip FORMCHECKBOX rhinitis FORMCHECKBOX sneezing FORMCHECKBOX poor sense of smell FORMCHECKBOX MusclesTender FORMCHECKBOX sore FORMCHECKBOX cramps FORMCHECKBOX spasms FORMCHECKBOX twitches FORMCHECKBOX loss of tone FORMCHECKBOX wasting FORMCHECKBOX weak FORMCHECKBOX stiff FORMCHECKBOX frozen FORMCHECKBOX ‘restless legs’ FORMCHECKBOX numbness FORMCHECKBOX SkinDry FORMCHECKBOX rough FORMCHECKBOX flaky FORMCHECKBOX scaly FORMCHECKBOX puffy FORMCHECKBOX pale FORMCHECKBOX brown patches FORMCHECKBOX change in moles or lesions FORMCHECKBOX prematurely lined FORMCHECKBOX congested FORMCHECKBOX oily FORMCHECKBOX clammy FORMCHECKBOX yellow FORMCHECKBOX slow to heal FORMCHECKBOX Skin prone toAcne FORMCHECKBOX pimples FORMCHECKBOX rosacea FORMCHECKBOX eczema FORMCHECKBOX dermatitis FORMCHECKBOX psoriasis FORMCHECKBOX rashes FORMCHECKBOX boils FORMCHECKBOX hives FORMCHECKBOX itching FORMCHECKBOX stretch marks FORMCHECKBOX cellulite FORMCHECKBOX easy bruising FORMCHECKBOX thread veins FORMCHECKBOX varicose veins FORMCHECKBOX ringworm FORMCHECKBOX allergic reactions FORMCHECKBOX excessive sweating FORMCHECKBOX Joints (fingers, knees, back, shoulders etc.)Painful FORMCHECKBOX inflamed FORMCHECKBOX swollen FORMCHECKBOX stiff FORMCHECKBOX rheumatic FORMCHECKBOX arthritic FORMCHECKBOX aching FORMCHECKBOX difficulty bending FORMCHECKBOX reduced mobility FORMCHECKBOX unsteadiness FORMCHECKBOX slow movement FORMCHECKBOX Mood (choose all that apply even if conflicting)Depressed FORMCHECKBOX anxious FORMCHECKBOX tense FORMCHECKBOX angry FORMCHECKBOX happy FORMCHECKBOX balanced FORMCHECKBOX optimistic FORMCHECKBOX sad FORMCHECKBOX pessimistic FORMCHECKBOX tired FORMCHECKBOX can’t be bothered FORMCHECKBOX hyperactive FORMCHECKBOX cheerful FORMCHECKBOX agitated FORMCHECKBOX easily upset FORMCHECKBOX tearful FORMCHECKBOX jittery FORMCHECKBOX frightened FORMCHECKBOX explosive FORMCHECKBOX pent up FORMCHECKBOX worried FORMCHECKBOX irritated FORMCHECKBOX annoyed FORMCHECKBOX overwhelmed FORMCHECKBOX suicidal FORMCHECKBOX fluctuating FORMCHECKBOX aggressive FORMCHECKBOX MindForgetful FORMCHECKBOX difficulty learning new things FORMCHECKBOX easily confused FORMCHECKBOX can’t switch off FORMCHECKBOX difficulty concentrating FORMCHECKBOX easily frustrated FORMCHECKBOX easily distracted FORMCHECKBOX difficulty making decisions FORMCHECKBOX loss of interest in daily life FORMCHECKBOX fogginess FORMCHECKBOX dyslexia FORMCHECKBOX dyspraxia FORMCHECKBOX insomnia FORMCHECKBOX hyperactive FORMCHECKBOX panic attacks FORMCHECKBOX no motivation FORMCHECKBOX ChestFrequent colds and chest infections FORMCHECKBOX asthma FORMCHECKBOX bronchitis FORMCHECKBOX palpitations FORMCHECKBOX heart condition FORMCHECKBOX chest discomfort/pain FORMCHECKBOX short of breath FORMCHECKBOX difficulty breathing FORMCHECKBOX hay fever wheezing FORMCHECKBOX persistent cough FORMCHECKBOX noisy breathing FORMCHECKBOX breast pain FORMCHECKBOX GutBloated FORMCHECKBOX painful FORMCHECKBOX tender FORMCHECKBOX cramping FORMCHECKBOX distended FORMCHECKBOX nausea FORMCHECKBOX hiatus hernia FORMCHECKBOX sensation of fullness FORMCHECKBOX acid reflux FORMCHECKBOX heartburn FORMCHECKBOX flatulence, belching FORMCHECKBOX churning FORMCHECKBOX vomiting FORMCHECKBOX irritable bowel FORMCHECKBOX coeliac FORMCHECKBOX diverticula FORMCHECKBOX polyps FORMCHECKBOX haemorrhoids FORMCHECKBOX ulcers FORMCHECKBOX sluggish FORMCHECKBOX sensitive FORMCHECKBOX constipation FORMCHECKBOX diarrhoea FORMCHECKBOX GenitalsItchy FORMCHECKBOX cystitis FORMCHECKBOX thrush FORMCHECKBOX ulcers FORMCHECKBOX warts FORMCHECKBOX herpes FORMCHECKBOX groin pain FORMCHECKBOX prostatitis FORMCHECKBOX pelvic inflammatory disease FORMCHECKBOX impotence FORMCHECKBOX painful intercourse FORMCHECKBOX vaginal dryness FORMCHECKBOX painful or frequent urination FORMCHECKBOX unexplained discharge FORMCHECKBOX HandsDry FORMCHECKBOX cracked FORMCHECKBOX eczema FORMCHECKBOX sore joints FORMCHECKBOX puffy FORMCHECKBOX cold FORMCHECKBOX chilblains FORMCHECKBOX tingling FORMCHECKBOX feel clumsy & uncoordinated FORMCHECKBOX poor circulation FORMCHECKBOX NailsFragile FORMCHECKBOX dry FORMCHECKBOX brittle FORMCHECKBOX flaky FORMCHECKBOX peeling FORMCHECKBOX split FORMCHECKBOX fungal FORMCHECKBOX hangnails FORMCHECKBOX Infected FORMCHECKBOX split cuticles FORMCHECKBOX ridged FORMCHECKBOX spoon shaped FORMCHECKBOX white spots on more than 2 FORMCHECKBOX horizontal white lines FORMCHECKBOX thickened or horny FORMCHECKBOX dark nails FORMCHECKBOX pale nail bed FORMCHECKBOX Legs & FeetRestless legs FORMCHECKBOX swollen FORMCHECKBOX aching FORMCHECKBOX athlete’s foot FORMCHECKBOX burning feet FORMCHECKBOX tender heels FORMCHECKBOX gout FORMCHECKBOX sciatica FORMCHECKBOX cold feet FORMCHECKBOX tingling FORMCHECKBOX numb FORMCHECKBOX prickling FORMCHECKBOX Your daily life________________________________________________Do you enjoy your daily life?___________________________________How may people depend on your support?_________________________________ Do you feel supported by people around you?_____________________________Are you recently separated/divorced/a new parent?__________________________________________________Are you recently bereaved?______________________________Have you moved house or changed jobs recently?__________________________________________Do you work long or irregular hours?_________________________________Is your workload bigger than you can manage?_______________________________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?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 pain?__________ Nausea or vomiting?__________ Flatulence or bloating?__________ 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 often do you have a bowel movement?__________ Have you noticed any recent change in bowel habit?__________ Are your stools pale, mid brown, dark brown, black, 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 of time on busy roads?_________Do you live close to an agricultural area?_________Do you drink unfiltered water?_________Do you drink alcohol? How many units a week _______?_________Do you smoke? How many ___________________________?_________Do you live in a smoky atmosphere?_________Do you think you may be addicted to anything?_________Do you spend a lot of time in front of a TV or VDU?_________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 aluminum?_________Do you regularly take antacid (indigestion) medication?_________Approximately what percentage of your food is organic?_________Do you frequently fry or roast food at high temperatures?_________Do you regularly eat browned or barbecued foods?_________Do you eat oily fish or shellfish more than 3 x a week?_________Do you regularly consume artificial sweeteners?_________Do you floss your teeth regularly?_________Are your teeth filled with mercury amalgams?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 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?Women only_________Are you pregnant? ______________________No. of 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 do you use?_________Are you still menstruating? Are your periods regular?_________Are you or have you been on HRT?_________Any bleeding or spotting in between?_________Are your periods particularly heavy or painful?_________Do you suffer from PCOS, fibroids, endometriosis?_________Any known genito-urinary conditions?_________Are you happy with your sex drive?Menstruating women please check box if you experience: pre-menstrual bloating FORMCHECKBOX tiredness FORMCHECKBOX irritability FORMCHECKBOX depression FORMCHECKBOX breast tenderness FORMCHECKBOX water retention FORMCHECKBOX headaches FORMCHECKBOX ____________________________________________Other?Menopausal women please check box if you suffer from: hot flushes FORMCHECKBOX insomnia FORMCHECKBOX osteoporosis FORMCHECKBOX mood swings FORMCHECKBOX depression FORMCHECKBOX vaginal dryness FORMCHECKBOX ____Other FORMCHECKBOX ?Men only_________Do you experience mood swings or depression?_________Loss of sex drive?_________Loss of motivation and drive?_________Any known genito-urinary conditions?_________Fertility problems?_________Problems achieving or maintaining an erection?_________Frequent or difficult urination?_________Prostate problems_________Wake at night to urinate_________Difficult to start or stop urine stream_________Pain or burning when urinatingEating HabitsWhat are your favourite foods?Which foods do you dislike?Which foods do you crave?Which food would you find hard to give up?__________ 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?__________ Are you allergic to any foods?__________ Do you suspect any foods don’t agree with you?__________ Have you recently changed your diet?__________ Do you eat on the move/when stressed?__________ Do you ever have eating binges?__________ What do you binge on?__________ Have you ever suffered from an eating disorder?__________ Do you chew your food thoroughly?__________ Are you excessively thirsty?How would you describe your overall diet? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________Health managementWhat is your GP’s Name? ________________________________________________Address: __________________________________________________________________Phone: _________________________________________________________________How did you hear about me? _________________________________________Are you under any other therapists or clinics? ______________________________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 my therapist to liaise with appropriate health professionals:Signed_____________________________________________Date________________Food diary – Please choose typical days and record as much information as possible e.g home cooked, fresh, packaged, whole, refined, organic etc. This helps to build an accurate picture of your diet.Name _____________________________________________________________________________________Date___________________________________________Weekday 1Weekday 2Weekday 3Day offDay offBreakfast (time)Lunch (time)Dinner (time)Snacks (times)Drinks CoffeeTea/caffeine/herbalWater/Fizzy/juice/ AlcoholOtherYour routine -Day 1Day 2Day offWake up timeGet up timeWork day start timeWork day breaks (total hours)Work day end timeTime spent travellingTime spent exercisingTime spent relaxing and type Other leisure activityOther routineTime spent outdoorsEnergy low timesOverall moodGo to bed timeFall asleep timeUninterrupted sleep? ................
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