QUESTIONNAIRE / HEALD NUTRITION Personalised dietary advice
for health & Wellbeing
This questionnaire is designed to provide us with the information on your diet health & lifestyle required to create a personalised nutritional programme specifically tailored for your needs. All information provided is treated in the strictest confidence. Please answer the questions as fully as possible (using the additional sheets provided if necessary),and return the completed questionnaire to Napiers clinic (18 Bristo Place, EdinburghEH1 1EZ) at least 3 days before your appointment.
OFFICE USE ONLY
DATE
REF
TITLE / NAME / DOB / AGE / M F
ADDRESS
EMAIL / HOME TEL / MOBILE
OCCUPATION / MARITAL STATUS
GP NAME & ADDRESS
OTHER HEALTH PROFESSIONALS / THERAPISTS INVOLVED IN YOUR CARE:
HOW DID YOU HEAR ABOUT HEALD NUTRITION?
HEALTH PROFILE
WHAT IS YOUR MAIN REASON FOR SEEKING NUTRITIONAL ADVICE?
WHAT HEALTH OUTCOMES ARE YOU HOPING TO ACHIEVE?
HEIGHT / WEIGHT / IS YOUR WEIGHT? / STABLE INCREASING DECREASING
MAIN HEALTH ISSUES
PLEASE LIST THE HEALTH ISSUES YOU WOULD LIKE TO FOCUS ON:
HEALTH ISSUE (EG DIGESTIVE PROBLEMS ALLERGIES, STRESS, TIREDNESS) / MANAGEMENT SO FAR (GP DIAGNOSIS, MEDICATION, OPERATIONS) / ONSET / DURATION
1.
2.
3.
HAVE YOU HAD ANY RECENT HEALTH TESTS? IF YES, PLEASE SPECIFY & GIVE RESULTS:
HAVE YOU HAD ANY OTHER DIAGNOSED CONDITIONS, MAJOR SURGERY, SIGNIFICANT PERIODS OF ILL HEALTH OR SUFFER FROM CHRONIC OR NIGGLING HEALTH PROBLEMS (EG FREQUENT COLDS)?
DO YOU SUSPECT YOUR HEALTH CONCERNS RELATE TO A PARTICULAR EVENT OR TIME IN YOUR LIFE?
MEDICATION
PLEASE LIST ANYTHING YOU TAKE REGULARLY
(EG PRESCRIBED MEDICATION, OVER THE COUNTER MEDICATION, SUPPLEMENTS & HERBAL REMEDIES)
MEDICATION / REASON FOR TAKING / CONDITION / DOSE / FREQUENCY / DURATION
HAVE YOU EVER TAKEN ANTIBIOTICS? IF SO WHEN AND FOR HOW LONG?
FAMILY HISTORY
PLEASE LIST ANY ILLNESSES OR CONDITIONS THAT YOUR FAMILY MEMBERS MAY SUFFER FROM
(EG HEART DISEASE, DIABETES, CANCER, ALLERGIES)
PARENTS: / GRANDPARENTS:
SIBLINGS: / CHILDREN:
LIFE STYLE
DO YOU ENJOY YOUR DAILY LIFE? / Y / N / DO YOU WORK LONG / IRREGULAR HOURS? / Y / N
HOW MANY PEOPLE DEPEND ON YOU FOR SUPPORT? / ARE YOU UNDER ANY OTHER SIGNIFICANT STRESS? / Y / N
DO YOU FEEL SUPPORTED BY THE PEOPLE AROUND YOU? / Y / N / IS YOUR JOB / DAILY LIFE ACTIVE? / Y / N
ARE YOU RECENTLY BEREAVED / SEPARATED / DIVORCED / NEW PARENT? / Y / N / DO YOU SMOKE? IF SO, HOW MANY PER DAY?
HAVE YOU MOVED HOUSE / CHANGED JOBS RECENTLY? / Y / N / DO YOU THINK YOU MAY BE ADDICTED TO ANYTHING? / Y / N
PLEASE RATE THE FOLLOWING USING THE SCALE BELOW:
HOW STRESSED YOU HAVE BEEN IN THE LAST MONTH?
LOW STRESS 1 2 3 4 5 6 7 8 9 10 HIGH STRESS
HOW MOTIVATED / CONFIDENT ARE YOU TO CHANGE YOUR DIET AND LIFESTYLE?
LOW MOTIVATION 1 2 3 4 5 6 7 8 9 10 HIGH MOTIVATION
DO YOU TAKE REGULAR EXERCISE? IF SO WHAT AND WHEN?
WHAT DO YOU DO FOR RELAXATION / HOBBIES?
WHAT TIME DO YOU USUALLY GO TO SLEEP / AWAKE?
DO YOU HAVE PROBLEMS SLEEPING? IF SO, PLEASE STATE:
ENERGY LEVELS
DO YOU NEED MORE THAN 8 HOURS SLEEP PER NIGHT? / Y / N / DO YOU GET DIZZY / IRRITABLE IF YOU DON’T EAT OFTEN? / Y / N
ARE YOUR ENERGY LEVELS LESS THAN YOU WANT THEM TO BE? / Y / N / DO YOU USE CAFFEINE / SUGAR / NICOTINE TO KEEP GOING? / Y / N
DO YOU FIND IT DIFFICULT TO GET GOING IN THE MORNING? / Y / N / DO YOU FIND IT DIFFICULT TO CONCENTRATE? / Y / N
DO YOU FEEL SLEEPY DURING THE DAY? / Y / N / DO YOU SUFFER FROM UNEXPLAINED FATIGUE / TIREDNESS? / Y / N
WHAT TIME(S) OF DAY IS YOUR ENERGY AT ITS LOWEST?
DIGESTION
DO YOU REGULARLY EXPERIENCE:
INDIGESTION / HEARTBURN / Y / N / BLOATING / WIND / Y / N
FREQUENT STOMACH UPSETS / Y / N / CONSTIPATION / Y / N
NAUSEA AND/OR VOMITING / Y / N / DIARRHOEA / Y / N
STOMACH PAINS / CRAMPS / Y / N / BLOOD / MUCUS IN STOOLS / Y / N
HOW OFTEN DO YOU HAVE A BOWEL MOVEMENT? / HAVE YOU EVER HAD A STOMACH UPSET DURING / AFTER FOREIGN TRAVEL / Y / N
IS YOUR URINE:
COLOURLESS PALE YELLOW DARK YELLOW SMELLY CLOUDY OTHER COLOUR …………………..
DO ANY FOODS CAUSE DIGESTIVE PROBLEMS, IF SO WHICH ONES?
WOMEN ONLY
ARE YOU PREGNANT? IF YES, HOW MANY WEEKS? / DO YOU HAVE CHILDREN? IF YES, HOW MANY?
ARE YOU BREAST FEEDING? / Y / N / ARE YOU STILL MENSTRUATING? / Y / N
ARE YOU TRYING TO BECOME PREGNANT? / Y / N / ARE YOU PERIODS REGULAR? / Y / N
SYMPTOM CLUSTERS
PLEASE CIRCLE OR UNDERLINE ANY SYMPTOMS / CONDITIONS THAT YOU REGULARLY EXPERIENCE
HEAD
Headaches Migraines Pounding head Stiff neck Dizziness Fuzzy headed Unexplained pain / HEART
Palpitations Heart condition Chest discomfort / pain
MUSCLES
Tender Sore Cramps Stiff Frozen Numbness Spasms Twitches Restless legs Loss of tone Wasting
MOOD
Happy Balanced Optimistic Hyperactive Cheerful Sad Tired Pessimistic Can’t be bothered Depressed Anxious Tense Angry Agitated Easily upset Tearful Jittery Frightened Explosive Worried Pent Up Irritated Annoyed Overwhelmed Loss of interest in daily life Suicidal Fluctuating Aggressive Panic attacks
JOINTS
(fingers knees back shoulders etc)
Painful Inflamed Aching Sore Swollen Stiff Rheumatic Arthritic Difficulty bending Reduced mobility
MIND
Difficulty concentrating Forgetful Brain fog Easily confused Easily distracted Difficulty making decisions Easily frustrated Can’t switch off Dyslexia Dyspraxia Insomnia Hyperactive
No motivation / LEGS & FEET
Restless legs Swollen Aching Burning feet Tender heels Tendonitis Plantar fasciitis Athlete’s foot Gout Sciatica Tingling Cold feet Numbness Prickling
SKIN
Dry Rough Flaky Scaly Prematurely lined Oily Clammy Puffy Pale Brown patches Change in moles or lesions
Slow to heal
HAIR
Oily Dry Poor condition Brittle Thinning Dandruff Excessive falling out Increased facial hair Increased body hair Decreased body hair
SKIN PRONE TO
Eczema Dermatitis Psoriasis Acne Pimples Boils Rashes Hives Itching Allergic reactions Easy bruising Stretch marks Cellulite Thread veins Varicose veins Ringworm
Excessive sweating
MOUTH
Strange taste Tooth decay Mouth ulcers Bad breath
Sore throat Sore tongue Cold sores Excess saliva Dry mouth Difficulty swallowing Hoarse voice Gingivitis Bleeding gums
HANDS
Dry Cracked Eczema Puffy Sore joints Cold Numbness Poor circulation Tingling Chilblains Clumsy & uncoordinated
NOSE
Frequent nose bleeds Congested Runny Postnasal drip Sneezing Sinusitis Rhinitis Hay fever Prone to snoring
CHEST
Frequent colds & chest infections Asthma Noisy breathing Bronchitis Wheezing Short of breath Difficulty breathing Persistent cough / NAILS
Brittle Flaky Peeling Split Fragile Dry Infected Fungal White spots on more than 2 nails Horizontal white lines Ridged Spoon shaped Thickened / horny Dark nails Pale nail bed
GUT / STOMACH
Painful Tender Cramping Nausea Vomiting Churning Gastroenteritis Frequent stomach bugs Hiatus hernia
Acid reflux Heartburn Belching Bloated Distended Sensation of fullness Sluggish Flatulence Sensitive Coeliac Irritable bowel Diverticulitis Polyps Haemorrhoids Ulcers Constipation Diarrhoea / GENITALS / REPRODUCTIVE SYSTEM
Itchy Inflamed Unexplained discharge Groin pain
Painful Intercourse Menopause Painful Periods Heavy Periods PCOS Vaginal dryness Endometriosis Fibroids Ulcers Warts Cystitis Thrush Herpes Pelvic inflammatory disease
Painful or Frequent Urination Prostatitis Impotence
IMPORTANT SYMPTOMS
PLEASE INDICATE BY UNDERLINING IF YOU SUFFER FROM ANY OF THE FOLLOWING SYMPTOMS WHICH MAY REQUIRE ADDITIONAL MEDICAL CARE:
Persistent / unexplained pain Unexplained bleeding or discharge from nipple / vagina / rectum Blood in sputum / vomit / urine / stools Breast lumps Calf swelling Difficultly swallowing Excessive thirst Increased urination Inability to gain / lose weight
Loss of appetite Paralysis Slurred speech Unexplained bruising / rash / weight Loss Black tarry stools Painless ulcers / fissures Bleeding in pregnancy
EATING HABITS
WHAT ARE YOUR FAVORITE FOODS?
ARE THERE ANY FOODS YOU DISLIKE?
DO YOU AVOID ANY FOODS FOR CULTURAL / ETHICAL REASONS? IF SO WHICH ONES
ARE THERE ANY FOODS WHICH YOU CRAVE?
WHICH FOODS WOULD YOU FIND DIFFICULT TO LIVE WITHOUT?
ARE YOU SENSITIVE / ALLERGIC TO ANY FOODS? IF SO WHICH ONES
DO YOU EVER HAVE EATING BINGES? IF SO WHAT DO YOU BINGE ON?
WHO DOES THE COOKING IN YOUR HOUSEHOLD?
DO YOU REGULARLY EAT ORGANIC: / FRUIT VEGETABLES MEAT DAIRY
WHAT TYPE OF BREAD, RICEAND PASTA DO YOU USUALLY EAT? / BREAD: / WHITE BROWN WHOLEMEAL GRANARY
PASTA: / WHITE WHOLEMEAL
RICE: / WHITE BROWN WILD
DO YOU EAT ON THE MOVE / WHEN STRESSED? / Y / N / DO YOU USE SALT IN YOUR COOKING / ADD IT TO YOUR FOOD? / Y / N
DO YOU EAT AT REGULAR TIMES EACH DAY / Y / N / DO YOU HAVE SUGAR IN YOUR HOT DRINKS, IF SO HOW MANY SPOONFULS PER CUP?
DO YOU REGULARLY MISS MEALS? / Y / N / DO YOU ENJOY COOKING / FOOD PREPARATION? / Y / N
HOW MANY TIMES A WEEK DO YOU EAT:
RED MEAT (BEEF LAMB PORK GAME) / CHOCOLATE / SWEETS
PROCESSED MEATS (HAM BACON SAUSAGES HAMBURGERS) / PUDDINGS
WHITE MEAT (CHICKEN TURKEY) / CAKES / BISCUITS
WHITE FISH (COD HADDOCK POLLOCK) / READY MEALS
OILY FISH (SALMON TROUT TUNA HERRING MACKEREL) / TAKE AWAYS / FAST FOOD
HOW MANY TIMES A WEEK DO YOU DRINK:
FOR ALCOHOL CONSUMPTION PLEASE STATE NUMBER OF UNITS CONSUMED PER WEEK
(1 UNIT = 1 SMALL GLASS OF WINE, ½ PINT BEER / LAGER / CIDER OR 1 MEASURE OF SPIRITS)
RED / WHITE WINE / BEER / LAGER / CIDER
SPIRITS / CANNED FIZZY DRINKS
COFFEE / TEA
WHICH COOKING METHODS DO YOU GENERALLY USE?
BOILING STEAM GRILLING DEEP- FRY SHALLOW FRY BAKE ROAST MICROWAVE
3 DAY FOOD DIARY
PLEASE CHOOSE 2 FAIRLY TYPICAL WEEKDAYS AND A WEEKEND / DAY OFF AND RECORD BELOW WHAT YOU ATE AND DRANK.
PLEASE GIVE AS MUCH INFORMATION AS POSSIBLE – EG PORTION SIZE, HOME COOKED (IF SO PLEASE STATE INGREDIENTS) OR SHOP BOUGHT, BRAND NAMES, FRESH, ORGANIC, WHOLEGRAIN / WHOLE WHEAT OR WHITE ETC
WEEKDAY 1 / WEEKDAY 2 / WEEKEND DAY / DAY OFF
BREAKFAST / TIME: / TIME: / TIME:
LUNCH / TIME: / TIME: / TIME:
DINNER / TIME: / TIME: / TIME:
SNACKS / TIME: / TIME: / TIME:
DRINKS / COFFEE / COFFEE / COFFEE
‘NORMAL’ TEA / ‘NORMAL’ TEA / ‘NORMAL’ TEA
GREEN / HERBAL TEA / GREEN / HERBAL TEA / GREEN / HERBAL TEA
FIZZY DRINKS / CORDIALS / FIZZY DRINKS / CORDIALS / FIZZY DRINKS / CORDIALS
UNITS OF ALCOHOL*
TYPE: / UNITS OF ALCOHOL*
TYPE: / UNITS OF ALCOHOL*
TYPE:
GLASSES OF WATER / GLASSES OF WATER / GLASSES OF WATER
OTHER DRINKS: / OTHER DRINKS: / OTHER DRINKS:
* 1 UNIT = 1 SMALL GLASS OF WINE, ½ PINT BEER / LAGER / CIDER OR 1 MEASURE OF SPIRITS
TERMS OF ENGAGEMENT(Issue 2.2 Dec 2012)
BETWEEN THE BANT NUTRITIONAL THERAPIST (NT) AND HIS/HER CLIENT
Please read and then sign and date the form below. If you have any queries please contact me.
The Nutritional Therapy Descriptor
Nutritional Therapy is the application of nutrition science in the promotion of health, peak performance and individual care. Nutritional therapy practitioners use a wide range of tools to assess and identify potential nutritional imbalances and understand how these may contribute to an individual's symptoms and health concerns. This approach allows them to work with individuals to address nutritional balance and help support the body towards maintaining health.
Practitioners consider each individual to be unique and recommend personalised nutrition and lifestyle programmes rather than a 'one size fits all' approach. Practitioners never recommend nutritional therapy as a replacement for medical advice and always refer any client with 'red flag' signs or symptoms to their medical professional. They will also frequently work alongside a medical professional and will communicate with other healthcare professionals involved in the client's care to explain any nutritional therapy programme that has been provided.
The Nutritional Therapist (NT) requests that the Client notes the following:
- The degree of benefit obtainable from Nutritional Therapy may vary between clients with similar health problems and following a similar Nutritional Therapy programme.
- Nutritional advice will be tailored to support health conditions and/or health concerns identified and agreed between both parties.
- Nutritional therapists are not permitted to diagnose, or claim to treat, medical conditions.
- Nutritional advice is not a substitute for professional medical advice and/or treatment.
- Your Nutritional Therapist may recommend food supplements and/or functional testing as part of your Nutritional Therapy programme and may receive a commission on these products or services.
- Standards of professional practice in Nutritional Therapy are governed by the CNHC Code of Conduct.
- This document only covers the practice of Nutritional Therapy within this consultation, and your practitioner will make it clear if he or she intends to step outside this boundary.
The Client understands and agrees to the following:
- I am responsible for contacting my GP about any health concerns.
- I give permission for you to contact my GP regarding any agreed aspects of my case: YES NO
- If I am receiving treatment from my GP, or any other medical provider, I should tell him/her about any nutritional strategy provided by my nutritional therapist. This is necessary because of any possible reaction between medication and the nutritional programme.
- It is important that I tell my nutritional therapist about any medical diagnosis, medication, herbal medicine, or food supplements, I am taking as this may affect the nutritional programme.
- If I am unclear about the agreed nutritional therapy programme/food supplement doses/time period, I should contact my nutritional therapist promptly for clarification.
- I must contact my nutritional therapist should I wish to continue any specified supplement programme for longer than the original agreed period, to avoid any potential adverse reactions.
- Recording consultations using any form of electronic media is not allowed without the written permission of both me and my Nutritional Therapist.
We understand the above and agree that our professional relationship will be based on the content of this document. We declare that all the information we share during this professional relationship is confidential and to the best of our knowledge, true and correct.
CLIENT NAME: / NT NAME:CLIENT SIGNATURE: / NT SIGNATURE:
DATE: / DATE:
ADDITIONAL INFORMATION
IF NECESSARY, PLEASE USE THIS SHEET TO CONTINUE YOUR ANSWERS
Charlotte Heald PhD MSc BSc(Hons) mBANT CNHC Reg
Napiers Clinic, 18 Bristo Place, EdinburghEH1 1EZ | 0131 225 5542 |
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