Nutritional Therapy Questionnaire

The questionnaire below is designed to help me assess your needs. Please take your time over it, as the more information I have to begin with, the more clues I will have to advise you on your nutritional and supplement needs. I may recommend testing to help us identify biochemical imbalances.

If you would like to download and print the form for completing and returning manually, please click here.

Otherwise, please continue below.

Personal details - Step 1 of 17

Personal details

Date of birth

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

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Health profile

What is your main reason for seeking nutritional advice? *

What outcome are you hoping to achieve? *

Please list the issues you would like to focus on

Health issue (e.g. arthritis, overweight) *

Management (e.g. surgery, exercise, drugs) *

Onset/duration *

Health issue 2

Management so far 2

Onset/duration 2

Health issue 3

Management so far 3

Onset/duration 3

Health issue 4

Management so far 4

Onset/duration 4

Have you had any recent health tests?

File Upload

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Have you had any diagnosed medical conditions, significant periods of ill health or do you suffer from any allergies, chronic or niggling health problems? (please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc.)

Have you had any surgery or biopsies, e.g. removal of tonsils, gall bladder, appendix, hysterectomy, hernia, colonectomy etc.

Do you suspect your symptoms relate to a particular event or time in your life?

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Medication and remedies

Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies.

Remedy

Dose

Condition being treated

Frequency and duration

Remedy 2

Dose 2

Condition being treated 2

Frequency and duration 2

Remedy 3

Dose 3

Condition being treated 3

Frequency and duration 3

Remedy 4

Dose 4

Condition being treated 4

Frequency and duration 4

Antibiotic history: please state when and why you last took antibiotics plus any previous times you can remember:

Nutritional supplements: please list any supplements you are taking, including the brand and dosage

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Body scan

Head

Headache
Migraine
Stiff neck
Fuzzy headed
Dizziness
Poor balance
Pounding head
Feeling of hangover
Unexplained pain

Mood

Depressed
Anxious
Tense
Angry
Happy
Balanced
Optimistic
Sad
Pessimistic
Tired
Can't be bothered
Hyperactive
Cheerful
Agitated
Easily upset
Tearful
Jittery
Frightened
Explosive
Pent up
Worried
Irritated
Annoyed
Overwhelmed
Suicidal
Fluctuating
Aggresive

Please check your predominant states, even if they conflict

Hair

Oily
Dry
Poor condition
Brittle
Thinning
Prematurely grey
Dandruff
Increased facial hair
Increased body hair
Decreased body hair

Mind

Forgetful
Difficulty learning new things
Easily confused
Can't switch off
Difficult concentrating
Easily frustrated
Easily distracted
Difficult to make decisions
Loss of interest in daily life
Fogginess
Dyslexia
Dyspraxia
Insomnia
Hyperactive
Panic attacks
No motivation

Mouth

Sore tongue
White/red patches
Tooth decay
Ulcers
Bad breath
Sore throats
Poor sense of taste
Excess saliva
Dry mouth
Difficult swallowing
Hoarse voice
Gingivitis
Bleeding gums
Cold sores

Eyes

Burning
Gritty
Protruding
Prone to infection
Sticky
Itchy
Painful
Poor night vision
Dry
Cataracts
Sensitive to light
Bags
Swollen eyelids
Blurred vision
Double vision
Failing eyesight
Yellowish

Chest/rib cage

Frequent cold and chest infections
Asthma
Bronchitis
Palpitations
Heart condition
Chest discomfort/pain
Short of breath
Difficulty breathing
Persistent cough
Noisy breathing
Breast pain
Pain under right side of rib cage

Ears

Blocked
Sore
Itchy
Weeping
Watery
Overly waxy
Creased earlobe

Nose

Congested
Runny
Frequent nose bleeds
Prone to snoring
Sinusitis
Hay fever
Post-nasal drip
Rhinitis
Sneexing
Poor sense of smell

Gut

Bloated
Painful
Tender
Cramping
Distended
Nausea
Hiatus hernia
Sensation of fullness
Acid reflux
Heartburn
Flatulence
Belching
Churning
Vomiting
Irritable bowel
Coeliac
Diverticula
Polyps
Haemorrhoids
Ulcers
Sluggish
Sensitive
Constipation
Diarrhoea

Muscles

Tender
Sore
Cramps
Spasms
Twitches
Loss of tone
Wasting
Weak
Stiff
Frozen
Restless legs
Numbness

Genitals

Itchy
Cystitis
Thrush
Ulcers
Warts
Herpes
Groin pain
Prostatitis
Pelvic inflammatory disease
Impotence
Painful intercourse
Vaginal dryness
Painful or frequent urination
Unexplained discharge

Skin

Dry
Rough
Flaky
Scaly
Puffy
Pale
Brown patches
Change in moles or lesions
Prematurely lined
Congested
Oily
Clammy
Yellow
Slow to heal

Hands

Dry
Cracked
Eczema
Sore joints
Puffy
Cold
Chilblains
Numbness
Tingling
Feel clumsy and uncoordinated
Poor circulation

Skin prone to

Acne
Pimples
Rosacea
Eczema
Dermatitis
Psoriasis
Rashes
Boils
Hives
Itching
Stretch marks
Cellulite
Easy bruising
Thread veins
Varicose veins
Ringworm
Allergic reactions
Excessive sweating

Nails

Fragile
Dry
Brittle
Flaky
Peeling
Split
Fungal
Hangnails
Infected
Split cuticles
Ridged
Spoon-shaped
White spots on more than 2
Horizontal white lines
Thickened or 'horny'
Dark nails
Pale nail bed

Joints

Painful
Inflamed
Swollen
Stiff
Rheumatic
Arthritic
Aching
Sore
Difficulty bending
Reduced mobility
Unsteadiness
Slow movement

Fingers, knees, back, shoulders, etc.

Back/shoulders

Tension/stiffness in shoulders
Pain between shoulder blades
Cervical/neck pain
Mid-back pain
Lower back pain

Legs and feet

Restless legs
Swollen
Aching
Athlete's foot
Burning feet
Tender heels
Sciatica
Cold feet
Tingling
Numb
Prickling
Leg or foot ulcer(s)
Flaking skin

Important symptoms

Persistent or unexplained pain
Unexplained bleeding or discharge from nipple, vagina or rectum
Blood in sputum (coughing up blood)
Vomit
Urine
Stools
Breast lumps
Calf swelling
Difficulty swallowing
Excessive thirst
Increased urination
Inability to gain or lose weight
Loss of appetite
Paralysis
Slurred speed
Unexplained bruising
Rash or weight loss
Black tarry stools
Painless ulcers or fissures
Bleeding in pregnancy

Please indicate if you suffer from any of these symptoms which may require additional medical care

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Your vital statistics

What is your normal blood pressure?

Your resting pulse rate?

Your current weight?

Your height?

Your waist circumference? (if known)

Your hip circumference? (if known)

Your blood type? (if known)

Is your weight stable, increasing or decreasing? *

Have you been vaccinated against Covid-19? If so, how many vaccinations have you had in total, and which make(s), if known (Astrazeneca, Pfizer, Moderna). When were your first and last doses?

Do you normally get an annual flu vaccination? If so, when was the most recent?

Did you have the recommended immunisations as a child?

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Your family history

Do you have a family history of disease or allergies? (e.g. heart disease, diabetes, asthma, etc.) State disease, age at onset, gender.

Grandparents

Parents

Siblings

Children

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Your daily life

Do you enjoy your daily life? *

How many people depend on your support? *

Do you feel supported by people around you? *

Are you recently separated/divorced/a new parent? *

Are you recently bereaved? *

Have you moved house or changed jobs recently? *

Do you work long or irregular hours? *

Is your workload bigger than you can manage? *

Are you under significant stress in any other way? *

Do you feel guilty when you are relaxing? *

Do you have a strong drive for achievement? *

Do you often do 2 or 3 tasks simultaneously? *

Do you take regular exercise? *

Is your job active? *

Do you have any active hobbies? *

Do you sleep well? *

What do you do for relaxation? *

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Your digestion

Do you regularly experience...

Indigestion (after food or between meals?) *

Indigestion after fatty food? *

Bowel movement shortly after eating? *

Frequent stomach upsets or stomach pain? *

Nausea or vomiting? *

Pain between the shoulders or under the ribs? *

Constipation or hard-to-pass stools? *

Diarrhoea or ‘urgency to go’? *

Blood or mucus in stools? *

Undigested food in stools? *

Generally inconsistent bowel movements? *

Anal itching? *

Thrush or cystitis? *

How often do you have a bowel movement? *

Have you noticed any recent change in bowel habit? *

Are your stools pale, mid brown, dark brown, black, grey? *

Have you ever had a stomach upset after foreign travel? If so, when was this? How was it treated? *

Do any foods cause digestive problems? (which ones?) *

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Your toxic exposure

Do you live, exercise or work in a city or by a busy road? *

Do you spend a lot of time on busy roads? *

Do you live close to an agricultural area? *

Do you drink unfiltered water? *

Do you drink alcohol? If so, how many units a week? *

What is your normal alcoholic drink? *

Do you smoke? If so, how many a day? *

Do you live in a smoky atmosphere? *

Do you think you may be addicted to anything? *

Do you spend a lot of time in front of a TV or VDU? *

Do you spend a lot of time on a mobile phone? *

Do you sunbathe much in the summer, or do you avoid the sun? *

Are you a frequent flyer? *

Are you exposed to chemicals through work or hobby? *

Do you heat, freeze or wrap food in plastics? *

Do you cook or wrap food in aluminium? *

Do you regularly take antacid (indigestion) medication? *

Roughly what percentage of your food is organic? *

Do you frequently fry or roast food at high temperatures? *

Do you regularly eat browned or barbecued foods? *

Do you eat oily fish or shellfish more than 3 x a week? *

Do you regularly consume artificial sweeteners? *

Do you floss your teeth regularly? *

Are your teeth filled with mercury amalgams? *

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Your energy levels

Do you need more than 8 hours sleep per night? *

Is your energy less than you want it to be? *

Do you find it difficult to get going in the morning? *

Do you feel drowsy during the day? *

What time(s) of day is your energy lowest? *

Do you get dizzy or irritable if you don’t eat often? *

Do you use caffeine, sugar or nicotine to keep going? *

Do you find it difficult to concentrate? *

Do you feel dizzy or light-headed if you stand up quickly? *

Do you suffer from unexplained fatigue or listlessness? *

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Eating habits

What are your favourite foods? *

Which foods (if any) do you dislike?

Which foods (if any) do you crave?

Which foods would you find hard to give up? *

Do you cater for a special diet in the household? *

Who does the cooking in your household? *

Do you avoid any food for cultural/ethical reasons? *

Are you allergic to any foods? *

Do you suspect any foods don’t agree with you? *

Have you recently changed your diet? *

Do you eat on the move/when stressed? *

Do you ever have eating binges? *

What do you binge on?

Have you ever suffered from an eating disorder? *

Do you chew your food thoroughly? *

Are you excessively thirsty? *

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Women Only

Are you pregnant? If so, how many weeks?

Are you trying to become pregnant?

Are you breast-feeding at present?

How many children have you had?

Have you had problems with fertility?

Have you ever had a miscarriage?

What contraception do you use?

Are you still menstruating?

Are you or have you been on HRT?

Are your periods regular?

Any bleeding or spotting in between?

Are your periods particularly heavy or painful?

Do you suffer from PCOS, fi broids, endometriosis?

Any known genito-urinary conditions?

Are you happy with your sex drive?

Menstruating women, please check if you experience:

Pre-menstral bloating
Tiredness
Irritability
Depression
Breast tenderness
Water retention
Headaches
Other

Other

Menopausal women, please check if you suffer from:

Hot flushes
Insomnia
Osteoperosis
Mood swings
Depression
Vaginal dryness
Other

Other

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Men only

Do you experience mood swings or depression?

Loss of sex drive?

Loss of motivation and drive?

Any known genito-urinary conditions?

Fertility problems?

Problems achieving or maintaining an erection?

Frequent or difficult urination?

Prostate problems

Wake at night to urinate

Diffi cult to start or stop urine stream

Pain or burning when urinating

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Your Health Carers

Is this your first visit to a Nutritional Therapist? *

How did you find out about me? *

What is your GP’s Name?

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Are any other therapists/clinics involved in your care? Please list:

Signature *

Date *

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Food diary - day 1

Please choose 2 fairly typical week days and a weekend or ‘day off’ and record as much as you can about your eating, sleep and leisure patterns. Please give as much information as possible - home cooked or not, brand names, fresh, packaged, whole, refined, organic etc. to help me to build an accurate picture of your lifestyle. If you would prefer to fill out a paper version of the food diary, please let me know and I will send you a PDF.

Breakfast

Date / Time

Date

Time

Lunch

Date / Time

Date

Time

Dinner

Date / Time

Date

Time

Snacks

Date / Time

Date

Time

Coffees

Sugar per cup

Normal teas

Sugar per cup

Green/herbal teas

Fizzy drinks/cordial

Units of alcohol (please specify what drinks)

Glasses of water

Your routine

Wake up time *

Get up time *

Work day start time

Work day breaks (no. of hours)

Work day end time

Time spent travelling (no. of hours)

Time spent exercising (no. of hours)

Type of exercise

Time spent relaxing (no. of hours)

Type of relaxation

Other leisure activity

Other routine

Time spent outdoors (no. of hours)

Energy low times

Overall mood *

Go to bed time *

Fall asleep time *

Uninterrupted sleep? *

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Food diary - day 2

Breakfast

Date / Time

Date

Time

Lunch

Date / Time

Date

Time

Dinner

Date / Time

Date

Time

Snacks

Date / Time

Date

Time

Coffees

Sugar per cup

Normal teas

Sugar per cup

Green/herbal teas

Fizzy drinks/cordial

Units of alcohol

Glasses of water

Your routine

Wake up time *

Get up time *

Work day start time

Work day breaks (no. of hours)

Work day end time

Time spent travelling (no. of hours)

Time spent exercising (no. of hours)

Type of exercise

Time spent relaxing (no. of hours)

Type of relaxation

Other leisure activity

Other routine

Time spent outdoors (no. of hours)

Energy low times

Overall mood *

Go to bed time *

Fall asleep time *

Uninterrupted sleep? *

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Food diary - day 3

Breakfast

Date / Time

Date

Time

Lunch

Date / Time

Date

Time

Dinner

Date / Time

Date

Time

Snacks

Date / Time

Date

Time

Coffees

Sugar per cup

Normal teas

Sugar per cup

Green/herbal teas

Fizzy drinks/cordial

Units of alcohol

Glasses of water

Your routine

Wake up time *

Get up time *

Work day start time

Work day breaks (no. of hours)

Work day end time

Time spent travelling (no. of hours)

Time spent exercising (no. of hours)

Type of exercise

Time spent relaxing (no. of hours)

Type of relaxation

Other leisure activity

Other routine

Time spent outdoors (no. of hours)

Energy low times

Overall mood *

Go to bed time *

Fall asleep time *

Uninterrupted sleep? *

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Email *

Personal details

Health profile

Please list the issues you would like to focus on

Medication and remedies

Body scan

Your vital statistics

Your family history

Your daily life

Your digestion

Your toxic exposure

Your energy levels

Eating habits

Women Only

Men only

Your Health Carers

Food diary - day 1

Your routine

Food diary - day 2

Your routine

Food diary - day 3

Your routine

Title