Nutritional Questionnaire
PRIVATE AND CONFIDENTIAL
All information contained within this questionnaire will remain strictly private and confidential.
Nutrition Programme Questionnaire
This questionnaire is designed to provide your Nutritionist with all the information necessary to build you an individual Nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.
First Name:
Last Name:
Address:
Post Code:
Email:
Tel No. (work):
(home):
Occupation:
Age:
What is your weight?
stone
lbs
What is your height?
feet
inches
Health profile
Please make a list of all the health problems you would like to clear up, and indicate how long you have had these problems eg. Headaches 5 years.
What medications (drugs) do you currently take? State daily doseage.
Under what circumstances do these problems improve?
Under what circumstances do they get worse?
What other illnesses have you had in the past ten years?
What operations have you had?
What is your normal blood pressure (don’t worry if you don’t know):
What is your resting pulse rate? (you should be sat down, relaxed and calm when you take your pulse. Your pulse can be found inside the bony protuberance on the thumb side of your wrist. Count the number of beats in 60 seconds).
Hereditary Profile
Do you have any children? If so, state age and sex.
How many brothers and sisters do you have? State age and sex.
Are there any illnesses that they suffer from?
What illnesses is / was your father prone to?
What illnesses is / was your mother prone to?
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Symptom Analysis
Each question in this section starts with a list of symptoms associated with Nutritional deficiency. Tick the contitions you often suffer from. Some symptoms are repeated; please tick them in all cases.
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1)
Mouth ulcers
Poor night vision
Spots
Frequent colds or infections
Dry flaky skin
Dandruff
Thrush or cystitis
Diarrhoea
2)
Back ache
Rheumatism or arthritis
Tooth decay
Hair loss
Excessive sweating
Muscle cramps or spasms
Joint pain or stiffness
Lack of energy
3)
Exhaustion after light exercise
Easy bruising
Slow wound healing
Lack of sex drive
Loss of muscle tone
Infertility
Varicose veins
4)
Frequent colds
Lack of energy
Frequent infections
Bleeding or tender gums
Easy bruising
Nose bleeds
Slow wound healing
Red pimples on skin
5)
Tender muscles
Eye pains
Irritability
Poor concentration
‘Prickly’ legs
Poor memory
Stomach pains
Constipation
Tingling hands
Rapid heart beat
6)
Burning or gritty eyes
Sensitivity to bright lights
Sore tongue
Cataracts
Dull or oily hair
Eczema or dermatitis
Split nails
Cracked lips
7)
Lack of energy
Diarrhoea
Insomnia
Headaches or migraines
Poor memory
Anxiety or tension
Depression
Irritability
Bleeding or tender gums
Spots
8)
Muscle tremors or cramps
Apathy
Poor concentration
Burning feet or tender heels
Nausea or vomiting
Lack of energy
Exhaustion after light exercise
Anxiety or tension
Teeth grinding
9)
Infrequent dream recall
Water retention
Tingling hands
Depression or nervousness
Irritability
Muscle tremors or cramps
Flaky skin
Lack of energy
10)
Poor hair condition
Eczema or dermatitis
Mouth over sensitive to hot
and cold
Irritability
Anxiety or tension
Lack of energy
Constipation
Tender or sore muscles
Pale skin
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11)
Eczema
Cracked lips
Prematurely greying hair
Anxiety or tension
Poor memory
Lack of energy
Poor appetite
Stomach pains
Depression
12)
Dry skin
Poor hair condition
Prematurely greying hair
Tender or sore muscles
Poor appetite or nausea
Eczema or dermatitis
13)
Dry rough skin
Dry eyes
Frequent infections
Poor memory
Loss of hair or dandruff
Excessive thirst
Poor wound healing
PMS or breast pain
Infertility
14)
Muscle cramps or tremors
Insomnia or nervousness
Joint pain
Tooth decay
High blood pressure
15)
Muscle tremors or spasms
Muscle weakness
Insomnia or nervousness
Irregular heart beat
High blood pressure
Constipation
Fits or convulsions
Hyperactivity
Depression
16)
Pale skin
Sore tongue
Fatigue or listlessness
Loss of appetite or nausea
Heavy periods or blood loss
17)
Poor sense of taste or smell
White marks on finger nails
Frequent infections
Stretch marks
Spots or Greasy skin
Low fertility
Pale skin
Depression
Poor appetite
18)
Muscle twitches
Childhood growing pains
Dizziness or poor sense of balance
Fits or convulsions
Sore knees
19)
Cataracts
Frequent infections
Family history of cancer
Signs of premature ageing
High blood pressure
20)
Excessive or cold sweats
Dizziness or irritability after 6 hours
without food
Need for frequent meals
Cold hands
Need for excessive sleep or
drowsiness during the day
Excessive thirst
‘Addicted’ to sweet foods
21)
Dry skin
Skin rashes / eczema
Dry hair / loss of hair
Dandruff
Joint pain
Depression
Dyslexia or learning difficulties
Hyperactivity
Excessive thirst
Chronic fatigue
PMS or breast pain
Asthma
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LifeStyle Analysis
Please tick for Yes or leave blank for No:
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Cardiovascular Profile
Is your blood pressure over 140/90?
Is your pulse rate after 15 minutes of rest above 75?
Are you more than 14lbs (7kg) over your ideal weight?
Do you do less than 2 hours of exercise a week?
Do you have more than 2 alcoholic drinks a day?
Is there a history of heart disease in your family?
Exercise Profile
Do you exercise for at least 20 minutes 3 times a week?
Do you regularly play sport?
Do you have any physically tiring hobbies?
Do you consider yourself physically fit?
Does your job involve vigorous activity?
Pollution Profile
Do you live in a city or near a busy road?
Do you spend more than 2 hours a week in traffic?
Do you exercise or play sports near a busy road?
Do you smoke more than 5 cigarettes a day?
Do you live or work in a smoky atmosphere?
Do you buy foods which have been exposed to exhaust fumes?
Do you generally eat non-organic foods?
Do you drink more than 1 unit or oz of alcohol a day?
(eg. 1 glass of wine / 1 beer/ 1 measure of spirit)
Do you spend a lot of time in front of a TV or computer?
Do you drink unfiltered tap water?
Stress Profile
Is your energy less now than it used to be?
Do you feel guilty when relaxing?
Do you have a persistent need for achievement?
Are you unclear about your goals in life?
Are you especially competitive?
Do you work harder than most people?
Do you easily become angry?
Do you often do 2 or 3 tasks simultaneously?
Do you easily become impatient?
Do you have difficulty sleeping?
Glucose Tolerance Profile
Do you often need more than 8 hours sleep a night?
Are you rarely awake after 20 minutes of rising?
Do you need something to get you going in the morning
Like tea, coffee or cigarette?
Do you consume tea, coffee, sugar containing foods, or cigarettes
at regular intervals through out the day?
Do you often feel drowsy during the day?
Do you become dizzy if you don’t eat often?
Do you avoid exercise/sports due to tiredness?
Do you sweat a lot or become excessively thirsty?
Do you sometimes have difficulty concentrating?
Is your energy less now than it used to be?
Digestion Profile
Do you chew your food properly?
Do you sometimes suffer from bad breath?
Are you prone to stomach upsets?
Do you often get a burning sensation in your stomach?
Do you find it difficult digesting fatty foods?
Do you occasionally have to take indigestion remedies?
Do you suffer from flatulence or bloating?
Do you suffer from any anal irritation?
Do you have a bowel movement daily?
Do your stools float?
Immune Profile
Do you get more than 3 colds a year?
Do you find it difficult to shift an infection?
Are you prone to urinary infections or thrush?
Do you take antibiotics more than twice a year?
Do you have a history of cancer in your family?
Have you had any lumps or growths biopsied?
Do you suffer from an inflammatory disease such as eczema, asthma,
or arthritis?
Do you suffer from hay fever?
Do you suffer from any allergies?
Please state which:
Have you had a major loss in the last year?
Metabolism Profile
Are you quick to fatigue / have poor stamina?
Do you gain weight easily and have difficulty losing weight?
Are you sensitive to cold?
Do you have a sluggish digestion?
Do you have dry skin / coarse hair?
Do you often feel depressed / have difficulty coping?
Do you have a low libido?
Do you suffer from excessive hair loss?
Do you need a lot of sleep?
Do you suffer from insomnia?
Do you have a strong sex drive?
Do you have a fast metabolism?
Do you find it difficult to put on weight?
Do you often feel anxious / nervous?
Intolerance Profile
Do you have any known/suspected food intolerances?
Please state which:
Have they been tested?
Are there any foods you crave or would find difficult to give up?
Please State which:
Do you suffer from any of the following symptoms:
Migraines/headaches
Facial puffiness
Itchy watery eyes
Dark circles under the eyes
Sinusitis
Excess sneezing
Constant sore throat
Excess mucous production
Joint pain/stiffness
Muscle aches/pains
Fluctuating fatigue
Fluid retention
Weight gain / weight fluctuations
Difficulty losing weight
Binge/compulsive eating
Food cravings
Itchy skin
Psoriasis
Asthma
Eczema
Dermatitis
Hay fever
Constipation
Diarrhoea
Bloating
IBS
Do you suffer from any of the following symptoms:
White coating on the tongue
‘Foggy’ head
Poor balance
Headaches
Grumbling stomach noises (when not hungry)
Thrush (oral or vaginal)
Athletes foot
Fungal nail infections
Skin rashes, itchy skin, hives
Poor memory, irritability, insomnia, mood swings, depression
Menstrual problems
Anal irritation
IBS symptoms ie) bloating, flatulence, constipation or diarrhoea
Weight problems
Are there any foods you will not eat?
How much water do you drink a day?
Questions for Women Only
Are you pregnant?
If so, how many weeks?
Are you trying to become pregnant?
Have you ever had a miscarriage?
Do you have an IUD fitted, or use a birth control pill?
Please State which:
Are your periods regular?
Are you post-menopausal?
Do you suffer from:
Pre-menstrual bloating
Tiredness
Depression
Breast tenderness
Headaches
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Please complete the three day food diary below:
Please fill in any supplements, e.g. vitamins/herbal remedies you are taking:
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