NCT Nutrition

PRE CONSULTATION QUESTIONAIRE

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
Address / Tel. no.
Mobile
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 / Doctor’s name & address
Tel. no.
Does your doctor know that you plan to see a Nutritional Therapist? Yes / no

GOALS

Which aspects of your health would you most like to improve?

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?
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 e.g. 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) / 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
Chest pain / 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

CURRENT DIAGNOSIS/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?
Have you taken any antibiotics recently?
Please give details of all current medication
Medication / Dose / Start date / Any side effects

ALTERNATIVE COMPLIMENTARY THERAPY

Please give details of any other therapy you have sought:
Please list any remedies (e.g. 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

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

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?

FAMILY MEDICAL HISTORY

What, if any, illnesses are present on your mother’s/father’s side of the family?
(E.g. heart disease/cancer/allergies etc.)
If you have any siblings, do they have any illnesses/conditions?

DIETARY HABITS

Is your diet based on any religious, personal, medical or other choice (e.g. 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?
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 etc.?
How much water do you drink daily?
How much tea and coffee do you drink daily?

3-DAY FOOD DIARY

In order to gain maximum benefit from your consultation, please write down exactly what you ate & drank. Please try to pick typical days.

How much / Food type / Time / Where / Alone/with whom / Activity / Mood

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

LIFESTYLE

How many units of ALCOHOL do you usually drink: / Per day? / 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/ e.g. 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? / 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 Sharon Schroeter has my permission to contact my medical doctor if she deems it necessary and beneficial for me (The patient).

I accept the Conditions of the Disclaimer (please sign)…………………………....Date………………

Please return completed & signed questionnaire and your completed food diary to Sharon Schroeter, 7D Stirling Avenue, Buccleuch, Sandton, 2090 or email to