Catherine Piner Nutrition - Health Questionnaire

NUTRITIONAL ASSESSMENT QUESTIONNAIRE

Please contact me to confirm your appointment before completing this health questionnaire.

All information is completely confidential.

Have a look through the questionnaire before attempting to complete, making sure you have all the information to hand, it’s important to give me as much detail as possible.

This health questionnaire will take at least 20 minutes to complete.

Please note in you will need to submit a 3 day food diary, please include 1 weekend day and include the approximate times of your meals and snacks, please have this to hand before starting this questionnaire.

Required *

Personal Information

First Name

Surname

Gender

MaleFemaleOther - Please Specify

Other - Please specify

Address

Phone

Date of Birth

Occupation

Marital Status

SingleMarriedWidowedDivorcedSeparatedOther - Please Specify

Other - Please specify (2)

Number of Children and their age

No children1 child2 children3 children4 children5 or more children

age of child

age of child (2)

age of child (3)

age of child (4)

age of child (5)

Weight (in kg)

Height (in cm)

Hip Circumference (in cm)

Waist Circumference (in cm)

Doctors name, address and phone number

Permission to contact your medical doctor

YesNo

Please list your 5 major health concerns in order of importance:

Are you?

- Pregnant
- Planning on becoming pregnant
- Experiencing fertility problems at this time
- Question not applicable

Have you had any blood tests done recently?

YesNo

Please specify why?

Any other tests carried out?

ColonoscopyEndoscopyOther - please specify

Other tests please specify

Please list all medication, current and past (including: the pill, antacids, painkillers, antibiotics, inhalers), include: name of medication, prescribed by, dosage, frequency and for how long?

Please list any supplements that you are currently taking or have taken in the past. Please give details. It would be helpful to bring these to the consultation.

Please list your illnesses/operations (excluding colds and flu), from childhood to current, please include illnesses and operations, age of onset, duration and any related medication:

Family History

Please list any illnesses or diseases in your family history, such as: Heart Disease, High Blood Pressure, High cholesterol, Osteoarthritis, Rheumatoid arthritis, Thyroid problems, Osteoporosis, Allergies, Obesity, Asthma, Depression, Alcoholism, Cancer, Type 1 Diabetes, Type 2 Diabetes (‘late onset’)

Family history

Past Lifestyle

Were you breastfed?

YesNo

Did you have all the childhood vaccinations?

YesNo

Did you have the regular childhood diseases, such as measles, chickenpox, mumps etc?

YesNo

What was your childhood diet like, please give details?

Would you consider yourself to have been a happy active child?

YesNo

Current Lifestyle

Sleep:

How many hours sleep do you get on average per night?

Does this feel like enough?

YesNo

On average, what time do you go to bed?

Do you have difficulty falling asleep?

YesNo

Do you wake in the night on a regular basis?

YesNo

Do you wake feeling refreshed?

YesNo

Exercise:

How much exercise do you do a week? Please give details

Is your job stationary or active? Please give details

Do you have any active or physically tiring hobbies? E.g. gardening, running, etc. Please give details.

Do you consider yourself to be fit?

YesNo

Stress:

Are you prone to getting easily impatient?

YesNo

Do you find it hard to say no to people?

YesNo

Do you tend to bottle up your feelings?

YesNo

Do you find it difficult to relax or guilty when you relax and do nothing?

YesNo

Do you have problems organising yourself and/or others?

YesNo

Are there currently any long-term stressful situations in your life? Please give details if you are comfortable doing so.

On a scale of 0 –10, 0 having no stress and 10 being extremely stressed, how would you rate your current stress level?

012345678910

Have there been long-term stressful situations in your past such as bereavement, separation, unemployment, career change or change of home location? Please give details if you are comfortable doing so

Have there.....

In times of stress, do you have a strong support network? (Friends, family, and/or community)

YesNo

Environmental Factors:

Do you work, exercise or live in a city?

YesNo

Do you have any amalgam (silver) fillings?

YesNo

Do you smoke regularly?

YesNo

smoke

Are there any smokers in your home?

YesNo

Do they smoke inside the house?

YesNo

Have you ever taken recreational drugs?

YesNo

drugs2

Do you work with or have regular contact with any chemical substances e.g. paints, solvents, dry cleaning fluid, weed killer?

YesNo

chemicals

Do you regularly drink tap water?

YesNo

Dietary Profile:

In your household who does the majority of the cooking? If it’s you, do you enjoy cooking?

Is your diet based on any religious or other rules?

YesNo

religious

Do you avoid any foods/food groups for medical reasons?

YesNo

medical

How would you describe your appetite?

GoodAveragePoor

Do you ever eat simply because you are bored, depressed or anxious?

YesNo

Do you often eat under stressful conditions or on the move?

YesNo

Do you eat out a lot or eat takeaway food?

YesNo

takeaway

Do you diet often?

YesNo

Diet often

How many units of alcohol do you drink per week on average (one unit = 125ml glass of wine, ½ a pint of beer or lager, a 25ml unit of spirits)?

How many teas and/or coffees do you drink per day?

Do you add sugar to tea, coffee or on cereal?

YesNo

sugar

Do you drink fizzy drinks

YesNo

Fizzy

Do you eat biscuits / chocolates / sweets / cake?

YesNo

Biscuits

Do you eat processed foods?

YesNo

Processed

Do you eat white bread / pasta / rice?

YesNo

Do you add salt to your food?

YesNo

Please list the foods that you particularly like:

Please list the foods that you particularly dislike:

Please complete your food diary:

Day 1

Breakfast

What time did you get up?

What time did you have breakfast?

What did you eat and drink?

Lunch

What time did you have lunch?

What did you eat and drink?

Dinner

What time did you have dinner?

What did you eat and drink?

Snacks

What time did you have snacks?

What did you eat and drink?

Day 2

Breakfast

What time did you get up?

What time did you have breakfast?

What did you eat and drink?

Lunch

What time did you have lunch?

What did you eat and drink?

Dinner

What time did you have dinner?

What did you eat and drink?

Snacks

What time did you have snacks?

What did you eat and drink?

Day 3

Breakfast

What time did you get up?

What time did you have breakfast?

What did you eat and drink?

Lunch

What time did you have lunch?

What did you eat and drink?

Dinner

What time did you have dinner?

What did you eat and drink?

Snacks

What time did you have snacks?

What did you eat and drink?

Are there any foods or drinks that you consume regularly that are not in the food diary?

YesNo

other food?

Symptoms

Please read the following list of symptoms and fill in the number that applies:

0 – No or do not have the symptom

1 – Yes, it is a mild symptom or rarely occurs (once a month or less)

2 - It is a moderate symptom or occasionally occurs

3 – It is a major symptom or is frequently occurs daily

Digestive Profile

Belching or gas within 1hr of a meal

0123

Belching

Heartburn (burning pain behind the breastbone)

0123

Heartburn

Acid Reflux

0123

Acid reflux

Use of antacids (Rennies or Gaviscon)

0123

Antacids

Bad breath

0123

Coated tongue

0123

Frequent stomach upsets

0123

Stomach upsets

Do you feel like skipping breakfast?

0123

Do you feel better if you don’t eat?

0123

Do your fingernails chip or break easily?

0123

Bloating

0123

Bloating

Abdominal pains or cramps associated with excess gas

0123

Abdominal pains or cramps not associated with excess gas

0123

Diarrhoea

0123

Alternating constipation and diarrhoea

0123

How many bowel movements do you have a day or week?

Black or tarry stools

0123

Blood in stool

0123

Blood in stool

Mucus in stool

0123

Mucus in stool

Undigested food in stools

0123

Light clay coloured stools

0123

Greasy or shiny stools

0123

Anus itching

0123

Known history of parasites, worms or bacterial infestations

0123

Known history of parasites, worms or bacterial infestations

Have you had any GIT investigations (endoscopy or colonoscopy)

YesNo

Have you had any GIT investigations (endoscopy or colonoscopy) (2)

Have you experienced any digestive disorder as a result of travelling abroad?

YesNo

Have you experienced any digestive disorder as a result of travelling abroad? (2)

Liver and Gallbladder

Are you easily intoxicated by alcohol?

0123

intoxicated

Frequent nausea

0123

Bitter taste in mouth especially after meals

0123

Sensitive to odours and / or perfume

0123

Strong reaction to caffeine – palpitations, feeling jittery or keeping you awake

0123

Sweat has a strong odour

0123

Strong reaction to medication such as antibiotics or the pill

0123

Fatigue

0123

Sensitive to tobacco smoke

0123

Dark circles under the eyes

0123

Yellow discolouration of the eyes and skin

0123

Frequent headaches

0123

Waking up at night (around 4am)

0123

Itchy skin or rashes

0123

Endocrine (Hormonal) System

Difficulty sleeping

0123

Require more than 8 hours sleep a night

0123

Hard to get going in the morning

0123

Need a stimulant e.g. coffee to get going in the morning

0123

Need a stimulant e.g. coffee, sugar or cigarettes to keep you going during the day

0123

Frequent fatigue

0123

Frequent drowsiness during the day

0123

Frequent drowsiness during the day

Dizziness or irritability if you don’t eat often

0123

Frequent sweating

0123

Excessive thirst

0123

Loss of concentration or short attention span

0123

Poor memory or memory has deteriorated recently

0123

Reduced energy

0123

Tendency to depression or social isolation

0123

Intolerance to cold or heat

0123

Intolerance to cold or heat

Cold hands or feet

0123

Weight gain / difficulty losing weight

0123

Frequent headaches

0123

Rapid or irregular heartbeat

0123

Nervousness or anxiety

0123

Teeth grinding

0123

Irritability

0123

Frequent migraines

0123

Immune System

Runny or drippy nose

0123

Runny or drippy nose

Frequent infections / colds and flu

0123

Frequent antibiotic use

0123

Frequent antibiotic use

Frequent cystitis

0123

Frequent cystitis

Frequent thrush

0123

Frequent thrush

Difficulty shaking off infections

0123

Never seem to get sick at all

0123

History of Epstein Bar, Herpes, Shingles, Chronic fatigue, Hepatitis or other chronic viral conditions

0123

History of Epstein Bar, Herpes, Shingles, Chronic fatigue, Hepatitis or other chronic viral conditions

Inflammatory conditions – e.g. eczema, hay fever, asthma or arthritis

0123

Inflammatory conditions – e.g. eczema, hay fever, asthma or arthritis

Skin conditions – e.g. eczema, acne or psoriasis

0123

Skin conditions – e.g. eczema, acne or psoriasis

Men Only

Prostate problems

0123

Difficult to stop or start urine stream

0123

Waking to urinate in the night

0123

Feeling of incomplete bowel evacuation

0123

Decreased sexual function

0123

Cardiovascular Health

7kg above ideal weight

0123

Shortness of breath with moderate exertion

0123

Muscle cramps with exertion

0123

Unexplained facial flushing where the face turns red

0123

Fainting or feeling light headed

0123

Heart palpitation or missed heartbeat

0123

Dull pain or tightness in the chest

0123

Numbness or tingling in the left arm

0123

“Air hunger” or sighing frequently

0123

Varicose veins

0123

Women Only

Please read the following list of symptoms and fill in the number that applies:

3 – happens with every period.

2 – happens a few times a year.

1 – has happened in the past.

0 – has never happened.

Depression around period

0123

Irritability around period

0123

Tearfulness around period

0123

Chocolate craving around period

0123

Breast tenderness around period

0123

Excessive menstrual flow

0123

Blood clots in menstrual flow

0123

Variations in menstrual cycle

0123

Weight gain around the hips, thighs and buttocks

0123

Excess facial hair

0123

Bloating or water retention around period

0123

Missed period

0123

Please answer the following to help me focus on the areas you would like to work on:

What would you like to get from this Nutritional Therapy consultation?

What has worked for you in the past?

What changes do you think you could make that may have the biggest impact on improving your health and wellbeing?

What is your main motivating factor for coming to see a Nutritional Therapist?

How much change are you capable of right now? (tick one of the following)

- I am willing to try anything - I feel I can cope with a moderate amount of change- I feel very anxious about changing my diet and lifestyle

Is there any additional information you think might be helpful?

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