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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