Questionnaire Name *FirstLastAddressEmail *GP Name/Surgery *Age *WeightHeightBlood pressureDo you live alone or with a partner/family?Do you have children? If so please indicate agePlease describe briefly the area /condition you would like help with: *Do you suffer from persistent or severe pain in any of the following areas: *HeadAbdomenChestEyeTempleOn passing urineOther (please state below)If you have chosen other please give more information hereDo you ever get blood in any of the following: *VomitStoolsUrineSaliva/spittle/sputumHave you noticed any recent changes in any of the following: *Level of thirstVisionSwallowingWeightUrinationBreathingAppetiteWaist sizeBowel movementsSkinBody/face shapePlease list any serious illnesses, health conditions, accidents or operations you have had (including childhood) Give an approximate date or state if ongoingPlease list all prescribed medication you are currently taking, dose & length of time taken:Include name of medication the dose and the length of time prescribedPlease list any over the counter medication you regularly take: (such as antacids, pain relief pills, anti-histamine, anti-inflammatory drugs, herbal and nutritional supplements)Include name of medication how often you take them and your reason for taking themFamily History - Please indicate if any of the following conditions run in your family *AlcoholismArthritisAsthma / Eczema / Hay FeverAutoimmune conditionCancerDepressionDementiaDiabetesHeart Disease / Stroke / High Blood PressureIBSCrohn’s Disease / Colitis / CoeliacObesityOsteoporosisNone of the aboveDigestion: *Nausea / VomitingDiarrhoeaConstipationBloatingBelching &/or flatulenceHeartburnIndigestionSense of excess fullness after eatingStomach pains/crampingDifficulty digesting fatty foodsPoor sense of taste or smellPoor AppetiteFood CravingsWhite coated tongueBloating within 1 hour of eatingNone of the aboveEmotions: *Mood SwingsAnxietyAnger / IrritabilityDepression / low mood Difficulty getting out of bedSpaced out / foggyPanic attacksNone of the aboveEnergy: *FatigueApathy / lethargyDifficulty relaxingDifficulty getting out of bedInsomniaNeed for tea/coffee/sugar drinks to keep goingNone of the aboveBlood sugar balance: *Wake in middle of night feeling anxiousCrave sweet foodsBinge or uncontrolled eatingSleepy after lunchHeadache if meal is skippedShaky if meal is delayedNone of the aboveImmune system: *Frequent infectionFrequent antibiotic useHistory of antibiotic useThrushCystitisProne to cold sores or mouth ulcersSinus problemsNone of the aboveWomen: *Painful periodsExcessive facial/body hairMood swings before periodsHeavy periodsIrregular periodsBreast tendernessFertility issuesNone of the aboveLiver: *Yellowish skin or eyesFeeling unwell after coffee &/or alcoholTenderness under right ribsBad reaction to chemicals /smoke /perfumeEasily intoxicated with wineNauseaNone of the aboveCardiovascular: *Aware of heavy or irregular breathingSwollen anklesChest PainsHigh cholesterolNone of the aboveHPA axis: *Difficulty gaining weightTend to be a night personDifficulty losing weightCrave salty foodsIntolerance to high temperaturesSensitive to bright lightsSensitive to coldDifficulty falling asleepHeadachesDizzy when standing up suddenlyMigrainesFeel wired or jittery after coffeeMorning headaches wear off in the dayPoor concentrationExcessive hair loss &/or coarse hairMuscle weaknessMentally sluggishPoor memoryLow libidoExcessive thirstNone of the aboveMen: *Difficulty urinatingWaking up more than once in night to urinateDecreased sexual functionUrinary tract infectionsLow libidoFertility problemsNone of the aboveGeneral:Watery or itchy eyesDecreased sense of smell or tasteCalf, foot or toe cramp at restPain or swelling in jointsCold sores, herpes lesionsCrave chocolateFeet have a strong odorHistory of anemiaDry mouth, eyes &/or noseWhite spots on finger nailsCrave fatty or greasy foodDry flaky skin or dandruffTension headaches at base of skullRacing heartRinging in the ears (Tinnitus)Nose bleeds &/or bruise easilyWhole body or limb jerks as falling asleepNight sweatsRestless leg syndromeFragile skin, easily chaffedHeart racesPolyps or wartsPlease tick any symptoms that apply to youNotes or other symptoms:Is your diet based on any religious, personal or other choice? (such as vegetarian, gluten-free, vegan etc) Please indicate what foods you avoid:Do you have any food allergies, intolerances or sensitivities that you know of or suspect? Please indicate what these might be:What are your favourite foods?What do you particularly dislike and avoid?Who does most of the cooking in your household?How often do you eat out?Eat ready-meals?Yes oftenYes OccasionallyNo neverHow often do you drink alcohol per week?What do you tend to drink and how many glasses do you drink when you have a drink?Do you exercise regularly and what sort of exercise do you do?Any other information you feel would be useful:Please read our data policy and agree to our terms before submitting your form: *I have read your data policy and agree to you using my informationBy submitting this form you are giving permission for Nutritional Matters to use the information you have provided for the purpose of providing nutritional advice.NameSubmit
