Women’s Nutritional Advisory Service
The Really Useful Health Company
Maryon Stewart
0208 068 0432
07460 684409
Email: enquiries@
GENERAL QUESTIONNAIRE
A. NAME AGE
ADDRESS PHONE (Home) (Work)
Email: ______________________________________________________________________________________________
Please complete all the questions on this form to the best of your ability. The information you provide will enable us to give you the best service we possibly can. If there is insufficient space, please use an additional sheet.
STRICT CONFIDENTIALITY WILL BE OBSERVED
The information you give will be respected and used only by us for your benefit and not divulged to any other agent for other purposes.
MARITAL STATUS
Single Married Divorced Separated Widowed
HEIGHT ft ins . AVERAGE WEIGHT st lbs
What is your ideal weight? st lbs
B. WHAT IS THE MAIN PROBLEM (S) FOR WHICH YOU ARE SEEKING HELP?
Please give details .
QUESTIONS FOR WOMEN
C. CONTRACEPTION
Present Contraception:
None The Pill Coil Sheath/Cap Female Sterilisation Male Sterilisation Other
Have you ever taken Oral Contraceptives? Yes No
Have you taken Oral Contraceptives in the last twelve months? Yes No
Are you currently trying to conceive? Yes No
Are you planning a baby in the near future? Yes No
PERIODS
How frequent are your periods? Every days How long do your periods last days?
Are your periods: Light Moderate Heavy
If menstruating, are your periods painful? Yes No Have you had a hysterectomy? Yes No
Are you currently menstruating? Yes No If yes, when, and are your ovaries remaining?
If no, how long ago was your last period?
PREGNANCIES
Please answer the following carefully. How many:
Pregnancies have you had Miscarriages/abortions Successful pregnancies
Current ages and birth weight of your children (Please state if breastfeeding now. Yes No )
1st Child Age Weight lbs oz 2nd Child Age Weight lbs oz
3rd Child Age Weight lbs oz 4th Child Age Weight lbs oz
Did you breast feed? Yes No
If yes, for how long in total Yrs months
D. SOCIAL CIRCUMSTANCES
Do you work as a housewife? Full Time Part Time Not at all
Do you have an occupation (as well)? Yes No
If so, what is it? Do you work: Full Time Part Time
Do you have a regular sexual partner? Yes No Do you live together? Yes No
E. IF YOU ARE STILL MENSTRUATING DO YOU SUFFER WITH PREMENSTRUAL SYNDROME?
Yes No If Yes, are your symptoms: Mild Moderate Severe
What are your worst symptoms?
How many days each cycle are these symptoms present?
F. HEALTH PROBLEMS
Please answer the following questions carefully (Tick one box per line)
Have any of the following ever been a problem to you?
|CONDITION |NEVER A PROBLEM |ONLY IN THE PAST |AT PRESENT |
|1. Eczema | | | |
|2. Asthma | | | |
|3. Nettle Rash/Urticaria | | | |
|4. Migraine | | | |
|5. Arthritis | | | |
|6. Frequent mouth ulcers | | | |
|7. Anaemia | | | |
|8. Recurrent vaginal thrush | | | |
|9. Other vaginal infections | | | |
|10. Recurrent cystitis | | | |
|11. Recurrent throat infections | | | |
|12. Recurrent cold sores | | | |
|13. Severe fatigue | | | |
|14. High blood pressure | | | |
|15. Kidney disease | | | |
|16. Multiple Sclerosis | | | |
|17. Epilepsy | | | |
|18. Bowel disease | | | |
|19. Diabetes | | | |
|20. Thyroid over-active | | | |
|21. Thyroid under-active | | | |
|22. Other hormone problems | | | |
|23. Breast problems - not cancer | | | |
|24. Ovarian cysts | | | |
|25. Endometriosis | | | |
|26. Cancer of the cervix | | | |
|27. Cancer of the breast | | | |
|28. Cancer of any other type | | | |
|29. Alcohol or drug addiction | | | |
|30. Severe depression | | | |
|31. Severe anxiety | | | |
|32. Other mental illness | | | |
|33. Low libido | | | |
|34. Panic attacks | | | |
|35. Palpitations | | | |
|36. Eating disorders | | | |
|37. Food craving | | | |
|38. Hair loss | | | |
|39. Infertility | | | |
|40. Osteoporosis | | | |
|41. Pelvic pain | | | |
|42. Period problems | | | |
Please give details of the above problems
G. ARE YOU CURRENTLY UNDER MEDICAL TREATMENT?: Yes No
Please give details
H. Please list DRUGS, MEDICINES (LAXATIVES, SEDATIVES & PAIN-KILLERS etc.) and all NUTRITIONAL SUPPLEMENTS that you take regularly or occasionally.
1. 2.
3. 4.
5. 6.
7. 8.
I. HAVE YOU HAD PREVIOUS TREATMENT FOR THIS CONDITION (S)? Yes No
If so, please give details
Was it helpful ?
J. TO YOUR KNOWLEDGE ARE YOU ALLERGIC TO ANY DRUGS, FOODS, CHEMICALS, CLOTHING etc Please give details
Are there any illnesses that run in your family?
K. SYMPTOM QUESTIONNAIRE
Below are a number of medical symptoms. Please tick any that are or have recently been a problem to you.
Yes Yes
Abdominal bloating Joint pains
Blood in the stool Difficulty bending
Poor appetite Increased curvature of the back
Constipation Loss of height
Anal irritation Pins and needles
Indigestion Giddiness
Diarrhoea Migraine
Wind Headaches
Excessive appetite or bingeing Fatigue
Cracked lips Insomnia
Mouth ulcers Mood swings
Sore tongue Excessively dry skin
Loss of taste Rough or pimply skin on the upper arms
Catarrh Acne
Blocked/runny nose Poor circulation ___________________________________
Repeated infections Ankle swelling
Swollen glands Restless legs at night
Muscle aches and pains or cramps Shortness of breath
Poor vision at night
Please give details of the above:
L. DO YOU CRAVE ANY OF THE FOLLOWING & IN WHAT QUANTITY IN ANY ONE DAY?
Chocolates Yes No 1-5 6-10 11-20 21 or more
Chocolate bars Yes No 1-2 3-4 5-6 7 or more
Sweets Yes No 1-5 6-10 11-20 21 or more
Alcohol Yes No 1-5 6-10 11-20 21 or more
Savoury foods Yes No 1-5 6-10 11-20 21 or more
Other foods Yes No Give details:
Are your cravings premenstrual only? Yes No
M. DIETARY QUESTIONNAIRE
1. How many cups do you drink per day of Tea Coffee
2. How many teaspoons of sugar do you add to your Tea Coffee
3. On average how many cigarettes do you smoke per day
4. On average how many `units’ of alcohol do you consume per day
(1 unit = 1 glass of wine = half pint of beer/lager = 1 spirit = sherry/vermouth)
Are you either: a VEGAN (eating only vegetable produce) a VEGETARIAN (eating everything except poultry or fish) an OMNIVORE (eating anything including some meat, poultry and fish)
IN ONE WEEK how many servings/portions do you have of:
Green vegetables Salads Red meat Poultry Fish Fresh fruit
Cakes/Biscuits (1portion = 1 cake = 3 biscuits) Chocolate Puddings/ice cream/sweet pies
Soft drinks (not low calorie) 1 can = 1 portion Chocolate based food/drinks Cola based drinks
IN ONE DAY how much of the following foods would you normally eat:
Bread
Wholemeal (not brown) White or brown slices Bran, or bran based cereal/muesli
Portions of dairy produce (1 portion = 4oz milk = 4oz yogurt (1 serving) = 2oz cheese)
Milk Yogurt Cheese Cream Butter Other animal fat
Do you add salt to your cooking? Yes No Do you add salt to your food at the table? Yes No
N. EXERCISE
How many times a week do you walk more than 2 miles or play a sport? e.g. swimming, keep fit, aerobics, (Please give details)
O. BEHAVIOUR AND SOCIAL ACTIVITIES
1. For how long have you had significant symptoms? Years Months
Do you consider that these symptoms have adversely affected the following, if yes score as follows:
Score 1= Mild 2 = Moderate 3 = Severe
2. Your home life/relationships with family/friends Yes No 1 2 3
3. Your work/career (leave blank if working as a housewife full time) Yes No 1 2 3
4. Your relationships with your sexual partner Yes No 1 2 3
HAVE YOU EVER
5. Contemplated suicide whilst suffering with these symptoms Yes No
If yes, how many times Once more than once more than 6 times
6. Been violent/aggressive towards others whilst suffering with these symptoms Yes No
If yes, how many times Once more than once more than 6 times
7. What is the worst problem these symptoms have created for you?
P. GENERAL QUESTIONS
1. Do you drive a car? Yes No
2. Do you consider your driving ability is affected by your symptoms Increased/decreased/the same
3. How do you consider your work efficiency/productivity is affected Increased/decreased/the same
by these symptoms. If decreased by how many days? 1-2 2-3 3-4 More
4. Do you think that other people, family, friends and work associates are
aware of a change in your behaviour when you are suffering? Yes No Give details
5. Since experiencing these symptoms has your frequency of sexual intercourse: Increased/decreased/the same
If decreased, please score as above 1 2 3
6. Since experiencing these symptoms has your enjoyment of sexual intercourse: Increased/decreased/the same
If decreased, please score as above 1 2 3
FEEDBACK
How did you hear about Maryon Stewart?
What prompt your decision to work with Maryon Stewart?
Is there anything else you would like to mention?
THANK YOU FOR COMPLETING THE QUESTIONNAIRE
PLEASE SEND TO ENQUIRIES@
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