Name
Address:
Doctor’s Address
Telephone Home Work Mobile:
Numbers:
Email address:
Age: / Date Of Birth: / Height: / Weight: / BMI: / Martial Status: / No. of Children:
LIFESTYLE
Profession& weekly working hours
How many times a week do you exercise and what form of exercise do you do
What do you do to relax & how many hours do you relax each day.
Do you drink / Yes / No / If yes, how many units do you consume per day/per week.
What type of drink do you consume
Do you smoke cigarettes/cigars, or use recreational drugs,
or
Are you’re a passive smoker / Yes / No / If yes, how many do you smoke a day & for how long have you smoked,or
How long have you been in close proximity to someone who does
Are you on any medication and/or
supplements / Yes / No / If yes, give details of brand & dosage & who prescribed them
WHAT ARE YOUR MAJOR HEALTH CONCERNS / LENGTH OF TIME HEALTH CONCERNS EXPERIENCED
WHAT TRIGGERS THESE HEALTH CONCERNS / DO YOU SYMPTOMS FLUCTUATE / WHAT MAKES THEM WORSE
YES / NO
YES / NO
YES / NO
ANY OPERATIONS OR ACCIDENTS IN THE PAST
IF YES, WHERE APPLICABLE GIVE DETAILS
YES / NO
YES / NO
YES / NO
ANY AVAILABLE MEDICAL OR FUNCTIONAL TEST RESULTS
IF YES, WHERE APPLICABLE GIVE DETAILS
YES / NO
YES / NO
YES / NO
FAMILY MEDICAL HISTORY OF BLOOD RELATIVES - IMMEDIATE & DISTANT
BLOOD GLUCOSE BALANCE
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
If a meal is missed do you suffer from:-
Fatigue/Weakness
Shakiness/Tremors
Less focused thoughts
Concentration poor
Irritability
Constantly wanting
Sweets
Tea
Coffee
Cigarettes
Frequent Anxiety
Need to consume Meals frequently
Breath smells like pear drops sweets
Unintended: -
Weight Gain
Weight Loss
Excessive: -
Appetite
Thirst
Urination: -
Frequent
Excessive
THYROID HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Feeling Tired and/or sleeping excessively
Finding it hard to loose Weight
Always feeling Cold
Cold feet/ Hands
Hair–Thinningcoarse, and/or
Loss of hair
Eyebrows - outer ⅓rdthinning or missing
THYROID HEALTH (Continued)
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Dry thickened skin especially around the heels
Constipation and/or poor Digestion
Often feel sluggish
movements and/or Thinking- Slow
Difficulty Coping and/or Depression
Infertility and/or
multiple Miscarriages
Menstrual Irregularities
Menstruation-heavy
and/or prolonged
ADRENAL HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Long-term Stress
Decreased ability to handle stress
Feeling of being
Rundown and/or Overwhelmed
Mild Depression
Less enjoyment or happiness with life
Decreased tolerance of people
Lethargy (i.e. lack of energy)
Increased effort to do every day tasks
taking longer to complete those tasks & to stay focused on those tasks
Difficulty getting up in the mornings
Sleep does not relieve fatigue
ADRENAL HEALTH (continued)
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Feeling better after evening meal/more awake during the evenings
Still feeling fatigued 30 minutes or longer after exercise
Decreased sex drive
Thoughts less focused, more fuzzy
Memory less accurate
Symptoms increase if meals are inadequate or missed
Increased PMS
Craving for salt and/or salty foods
Light-headed when standing up quickly
Increased time to recover from illness, injury or trauma
HEART HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Diagnosed with a Cardiovascular Disease
High Blood Pressure
High Cholesterol
Easily out of breath when doing the following and/or
Chest pains when: -
Walking
Walking briskly
Climbing the stairs Running
Prone to central obesity
DIGESTIVE HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Coeliac Disease
Irritable Bowel Disease (IBD): -
Ulcerative Colitis
Crohn’s Disease
Irritable Bowel Syndrome (IBS)
Colon Cramps
Constipation
Difficulty in passing stools
Diarrhoea
Abdominal bloating
Excessive flatulence
Indigestion
Heavy feeling within 30 minutes after a meal
Undigested food in stools
Do you eat in a hurry & therefore don’t chew your food well
What is the condition of your nails
Abdominal bloating after eating fruit
Gastritis
Ulcers: -
Gastric
Duodenal
Heartburn
Acid reflux
Sour taste in the mouth
Liver diseases
Gallstones
Colic
Alcohol intolerance
Stools: -
Light or clay coloured
DIGESTIVE HEALTH (continued)
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Fatty foods cause: -
Nausea/Indigestion
Eyes or Skin: -
light yellow in colour
Often taken: -
Antibiotics
Recently taken Antibiotics
Often taken: -
NSAIDs e.g. Ibuprofen/Aspirin/
Paracetamol
Food Allergies
Food Intolerances
Sensitive to the smell of chemicals and/or perfumes
Find gaining weight difficult
Thrush: -
vaginal and/or oral
Parasitic infection
Itching around the rectum
IMMUNE HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Cancer
Auto immune disease
Frequent: -
Infections
Colds
Dental infections
Cystitis
Cold sores
Lymph glands: -
Sore
Swollen
Often taken Steroids or recently taken
Steroids
OTHER HEALTH CONDITIONS
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Diabetes
Type 1 (insulin dependant)
Type 11
Chronic Fatigue Syndrome
Fibromyalgia
Multiple Chemical Sensitivity
Inflammatory Conditions e.g.
Asthma
Eczema
Dermatitis
Psoriasis
Hay Fever
Urticaria (Hives)
Acne
Depression
Migraines
Sinusitis
Excessive Mucus production
Constant runny nose
Constant sore throat
Sneeze excessively
Eyes: -
Watery
Itchy
Dark circles under the eyes
Joint: -
Pain
Stiffness
Muscle: -
Pain
Aches
Skin: -
Rashes
Itchy
Fluid retention
(not related to PMS)
OTHER HEALTH CONDI TIONS (continued)
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Insomnia
Sleep Disturbance
Weight gain: -
Rapid
Large
Weight Loss: -
Rapid
Large
Eating Disorders: -
Anorexia
Bulimia
Other
Binge eating
Comfort eating
Are there any foods or drinks in particular that make you feel bloated after consuming
EXPOSURE TO TOXINS
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Amalgam dental fillings
Amalgam dental fillings removed
Living: -
In a city
Near a busy main road
Industrial or chemical buildings
Working with: -
Chemicals
Toxic metals
At a petrol station
Glass makers
WOMENS HEALTH
Do you now, or have ever suffered from any of the following: -
Yes / No / If yes, where applicable give details
Are you: -
Pregnant or
lactating
Trying to get pregnant
IVF Treatment: -
previously/current
Ever miscarried
Taking: -
Contraceptives: -
Oral/Implant
IUD (Coil)
& if so how long for
Irregular periods
Heavy periods
Painful periods
PMS symptoms: -
Anxiety
Irritability
Tension
Mood Swings
Sweet Cravings
Fatigue
Headaches
Breast tenderness
Bloating
Water retention
Weight Gain
Crying
Depression
Forgetfulness
Pre-menopause
(periods still regular + symptoms)
Peri-menopause
(irregular period +
symptoms)
Post-menopause
(cessation of periods & symptoms)
Taking HRT & if so how long for
FOOD CHOICES & EATING PATTERNS
Do you have any food restrictions/exclusions
Do you have any cravings for any particular foods
How many meals do you eat each day
Do you eat snacks between meals
Do you consume white or brown / bread / pasta / rice / How often eaten
Do you consume / cakes / biscuits / How often eaten
Do you add sugar to hot drinks, if so how much
How many portions of vegetables do you eat daily / Please list the types of vegetables that you eat
How many portions of Fruit do you eat daily / Please list the types of fruit that you eat
Do you add salt to your meals, if so how much
Do you add sauces to meals, ifso how much & what type
How many times each week do you eat processed & ready cooked meals & if so what type
How many times each week do you eat at fast food restaurants/outlets
How many times each week do you eat
take-away meals / Please list the types of take-away foods that you eat
Do you consume tinned foods / Please list the types of tinned foods that you eat
Do you consume frozen foods / Please list the types of frozen foods that you eat
What methods of cooking do you use e.g. deep fry, microwave, Bar-B-Q, steam, stir fry etc
How much water do you drink daily / Tap, bottled or filtered water
Do you drink Herbal teas, if so how many cups daily & what type
Do you drink normal Tea, if so how many cups do you drink daily
Do you drink Coffee, if so how many cups do you drink daily
What types of fizzy drinks do you consume
How many bottles/cans/glasses daily
TY PICAL WEEKDAY DIET
DAY 1
Meal / Time / Description-including portion sizes where applicable
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Evenings
Daily Drinks
(inc Alcohol)
DAY 2
Meal / Time / Description-including portion sizes where applicable
Breakfast
Mid-Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Evenings
Daily Drinks
(inc Alcohol)
TY PICAL WEEKEND DIET
SATURDAY
Meal / Time / Description-including portion sizes where applicable
Breakfast
Mid-
Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Evenings
Daily Drinks
(inc Alcohol)
SUNDAY
Meal / Time / Description-including portion sizes where applicable
Breakfast
Mid-
Morning Snack
Lunch
Mid-Afternoon Snack
Dinner
Evenings
Daily Drinks
(inc Alcohol)
If there is any other information that you would like to add that you think may be beneficial
What would you like to achieve from this Consultation
Practitioner’s comments
Patient’s Signature…………………………………………………… Date……………………………..
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