Name

Age

Email Address

Phone Number

Address

Occupation

Main reasons for seeking nutritional advice?

What health outcomes would you like to achieve?

1. Any Health conditions? 1. Any Health conditions? 1. Health conditions

Nature of Health Condition?

Date of onset and treatment?

Diet/lifestyle changes that make it better?

Diet/lifestyle changes that make it worse?

2. Medication & nutritional supplements past and present?

3. Have you had major surgery, diagnosed heath conditions or significant periods of ill health?

4. Family history - major diseases in biological family

5. Personal health information - Height / Weight?

Blood Pressure (If Known)

6. GP name and address?

7. Systems and symptoms review - tick any of the conditions that you regularly experience? 7. Systems and symptoms review - tick any of the conditions that you regularly experience?

Digestion Digestion Bloating/trapped wind/stomach pain? Irregular bowel movements? Diarrhoea? Constipation? Indigestion / acid reflux / heartburn? Bad breath? Blood/mucus/undigested food in stools?

Nervous System Nervous System Headaches / Migraine? Chronic fatigue / Low energy Anxiety / Depression Fainting / Dizziness / Visual disturbance

Endocrine System Endocrine System Sugar cravings? Needing to eat at least every 3 hours or less? Excessive thirst / frequent urination? Weight gain? Weight loss? High stress levels?

Reproductive - Female Reproductive - Female Fertility problems? Still menstruating? Regular cycle? PMS symptoms? Thrush or cystitis? Pre/post menopausal?

Reproductive - Male Reproductive - Male Fertility problems? Frequent/difficult urination? Groin pain? Any children?

Immune Immune Asthma / Eczema / Rashes? Allergies / Intolerances? Frequent infections? Herpes / Colds sores / Athletes foot? Antibiotics taken over the years?

Respiratory & cardiovascular system Respiratory & cardiovascular system Sinusitis? Frequent sore throat / Persistent cough? Chest pain? Asthma / Wheezing / Bronchitis? High blood pressure? Cholesterol levels? Post nasal drip / Excessive mucus?

Skin Skin Acne? Dry skin? Sensitive skin? Easily inflamed? Oily skin? Dermatitis / Psoriasis? Fungal infections?

Muscular-skeletal Muscular-skeletal Joint pain? Arthritis / Rhematoid Arthritis? Back or neck pain? Muscle spasms / Cramping?

Any other conditions not mentioned or extra information you deem relevant?

8. Mental wellbeing & lifestyle 8. Mental wellbeing & lifestyle

How to do you rate your current stress levels (1 to 10) How to do you rate your current stress levels (1 to 10)12345678910

How to you rate how happy you currently are (1 to 10) How to you rate how happy you currently are (1 to 10)12345678910

How to you rate your energy levels (1 to 10) How to you rate your energy levels (1 to 10)12345678910

Do you enjoy and find your job rewarding? Do you enjoy and find your job rewarding? Yes No Sometimes

Have you recently moved house/changed jobs/been bereaved? Have you recently moved house/changed jobs/been bereaved? Yes No

Do you feel guilty when relaxing? Do you feel guilty when relaxing? Yes No Sometimes

Do you sleep well? Do you sleep well? Yes No Mostly

How many hours per night?

Do you smoke? Do you smoke? Yes No In the past

Do you drink alcohol? Do you drink alcohol? Yes No

How many units per week?

Do you exercise? Do you exercise? Yes No

How much per week?

9. Typical food intake over 5 days 9. Typical food intake over 5 days

Breakfast

Lunch

Dinner

Drinks

Snacks