NUTRITIONAL THERAPY PRE-CONSULTATION QUESTIONNAIRE

1 NUTRITIONAL THERAPY PRE-CONSULTATION QUESTIONNAIRE Please write clearly and answer the questions as accurately as possible as this will help your treatment. All information given will be treated as strictly confidential. GENERAL INFORMATION Date QUESTIONNAIRE completed Name Title Tel. no. Mobile Address E-mail Marital Status Date of Birth Age Occupation Number of children, their ages and gender: Height Weight Blood group, if known Blood pressure, if known Are you currently planning to become a parent? Pregnant? Or experiencing fertility problems? Permission to contact your medical doctor? Yes / no Does your doctor know that you plan to see a NUTRITIONAL Therapist? Yes / no Doctor s name & address Tel. no. GOALS Which 3 aspects of your health would you most like to improve? 1 2 3 2 HEALTH/SYMPTOM SCREEN If you have problems in any of the areas below, please rate the severity of the symptoms by marking the appropriate box next to the symptom where; 1 = Mild 2 = Moderate 3 = Severe DIGESTIVE TRACT 1 2 3 MIND 1 2 3 Nausea or vomiting Poor memory Diarrhoea Confusion, poor comprehension Constipation Poor concentration Bloated feeling Poor physical co-ordination Belching or passing wind Difficulty m

5 DIETARY HABITS Is your diet based on any religious, personal, medical or other choice (e.g. Hindu, Muslim, vegetarian, vegan, gluten-free etc)?

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