NUTRITIONAL THERAPY PRE-CONSULTATION QUESTIONNAIRE

1 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 making decisions Heartburn Are any of the above made worse by skipping meals?

2 EARS 1 2 3 MOUTH/THROAT 1 2 3 Itchy ears Chronic cough Earaches, ear infection Gagging Drainage from ear Frequent need to clear throat Ringing in ears, hearing loss Sore throat, hoarseness, loss of voice Sore tongue EMOTIONS 1 2 3 Prone to cold sores Mood swing Anxiety, fear or nervousness NOSE 1 2 3 Anger, irritability, aggressiveness Stuffy nose or sinus problems Depression Hay fever Excess mucus formation ENERGY/ACTIVITY 1 2 3 Sensitive to strong smells petrol perfume Fatigue/sluggishness Apathy/lethargy SKIN 1 2 3 Hyperactivity Acne Restlessness Hives, rash or dry skin Hair loss EYES 1 2 3 Flushing or hot flushes Watery or itchy eyes Excessive sweating Swollen, reddened sticky eyelids Soft, fraying or brittle nails Sensitivity to bright light Blurred or tunnel vision (not including near or far sight)

3 WEIGHT 1 2 3 Water retention HEAD 1 2 3 Binge eating & drinking Headache Cravings for certain foods Faintness or dizziness Compulsive eating Insomnia Lack of appetite HEART 1 2 3 WOMEN 1 2 3 Irregular or skipped heartbeat Menstrual pain Rapid or pounding heartbeat Tender/painful breasts Chestpain Mood change before period JOINT / MUSCLES 1 2 3 OTHER 1 2 3 Pains or aches in joints Frequent illness Arthritis or rheumatism Frequent or urgent urination Stiffness or limitation General itch or discharge Feeling of weakness or tiredness Excessive thirst Loss of taste or smell LUNGS 1 2 3 Chest congestion/ wheezing Asthma Shortness of breath Difficulty breathing 3 CURRENT DIAGNOSES/TREATMENT Have you received a diagnosis for any of your symptoms or complaints from a medical doctor? If yes, have you received any conventional treatment/medication/ tests?

4 Have you taken any antibiotics recently? Please give details of all current medication Medication dose Start date Any side effects (Please continue on another page if necessary) ALTERNATIVE COMPLEMENTARY THERAPY Please give details of any other THERAPY you have sought: Please list any remedies ( herbal/homeopathic etc.) or NUTRITIONAL supplements that you take: Remedy/supplement dose Start date Any side effects PLEASE BRING ANY SUPPLEMENTS / REMEDIES TO YOUR CONSULTATION 4 MEDICAL HISTORY Please list your illnesses/operations (excluding colds & flu) starting from your childhood and including any current problems Illness/operation Age of onset Duration Medication/treatment (Please continue on a separate sheet if necessary) TRAVEL Have you been abroad in the last 5 years? Please specify where: Have you suffered from digestive illnesses/problems either whilst abroad or after returning from abroad?

5 FAMILY MEDICAL HISTORY What, if any, illnesses are present on your mother s/father s side of the family? ( heart disease/cancer/allergies etc. ) If you have any siblings, do they have any illnesses/conditions? 5 DIETARY HABITS Is your diet based on any religious, personal, medical or other choice ( Hindu, Muslim, vegetarian, vegan, gluten-free etc)? please specify Do you have any special dietary requirements? please specify Have you been on/are currently on any specific diets? Please specify / give duration? How many times a week do you consume ready meals? How often do you cook at home? Do you regularly miss meals? List your favourite foods Are there any foods that you would find hard to give up? Do you crave any particular foods? Are there any foods or drink that cause your symptoms to worsen? TYPICAL FOOD CONSUMPTION How many portions of vegetable/salad (excluding potatoes) do you typically eat each day?

6 How many portions of fruit (including dried fruit and fruit juice) do you typically eat each day? How many portions of carbohydrate do you typically eat each day? (cereals, bread, pasta, rice and potatoes) How often do you eat red meat? (beef, lamb & pork) How often do you eat processed meat? (bacon, ham, sausage, salami) How often do you eat fish? How often do you eat cheese, cream, butter and yoghurt? How much cow s milk do you consume? How often do you eat chocolate or confectionary? How often do you eat snack foods (crisps, salted nuts How much water do you drink daily? How much tea and coffee do you drink daily? MOTIVATION How motivated are you to change the way you eat and experiment with new foods? I will try anything that might improve my condition I feel I can cope with a moderate amount of change I feel very anxious about changing my diet 6 LIFESTYLE How many units of ALCOHOL do you usually drink: Per day?)

7 Per week? Per weekend? 1 pint of lager/beer = 2 units 1 glass of wine = 2 units 1 pub measure of spirits = 1 unit What do you drink? Beer/lager wine spirits Other How would you best describe your drinking habits? Minimal social Small amounts frequently Large amounts infrequently Large amounts frequently Do you take regular EXERCISE? Please specify: Would you describe yourself as: VERY ACTIVE ACTIVE MODERATELY ACTIVE SEDENTARY Do you SMOKE? Y/N If so how many per day? If you have stopped smoking when did you give up? On a scale of 1-10 with 10 being the highest, how would you rate your current stress levels? Are there any issues that make you feel STRESSED at the moment/ major life change (new job, parenthood, moving house, becoming a parent) Do you have a difficult time getting to sleep? Do you wake up in the night? How many hours sleep do you usually get? Do you find it hard to get up in the morning? Do you find it hard to relax?

8 Do you feel rushed/edgy most of the time? What do you do to relax? Are your symptoms affecting any activities, such as socialising, driving, housework? Is there any other information relating to your condition, which you think may be important? DISCLAIMER I understand that NUTRITIONAL THERAPY is not a substitute for professional medical treatment and that the NUTRITIONAL Therapist does not diagnose medical conditions, but may help manage them through diet and the use of supplements. Therefore I accept that Joanna Oates has my permission to contact my medical doctore if she deems it necessary and beneficial for me (The patient). I accept the Conditions of the Disclaimer (please sign).. Please return completed & signed QUESTIONNAIRE and your completed food diary to Joanna Oates, 12 Leythe Rd, Acton, LONDON, W3 8AW or email to 1 week before your consultation 7