info@nu-boosthealth.co.uk | 07813 018 908
Please fill answer all questions as accurately as you can. The information provided is used by your nutritionist to provide you with an individual tailor-made dietary programme. All information provided will be treated in strictest confidence.
Title (required)
First Name (required)
Last Name (required)
Your Email (required)
Address
Postcode
Home Number
Mobile Number
Occupation
Date of Birth
Weight
Height
Please tick the box if you give permission for your nutritional therapist to contact your doctor if required Yes No
GP’s name
GP’s Tel no
GP’s Address
Please state any health concerns you would like help with and indicate how long you have had them:
Health Concern
Duration (months)
Under what circumstances do these problems improve?
Under what circumstances do these problems get worse ?
Are you currently taking any medication/drugs? Yes No
If yes, state product, dose and duration
Supplements taken
Do you have any known allergies? Yes No
If yes, state what and type of reaction
Have you been tested for allergies? Yes No
If yes, state test and details of results
Have you undergone any operations ? (give dates and condition)
What other illnesses have you had in the past ? (give dates and condition)
Do you have any children ? (if yes, indicate age, sex and any illnesses and/or conditions)
Do you have any brothers and/or sisters ? (if yes, indicate age, sex and any illnesses and/or conditions)
Do/did you parents or grandparents suffer from any illnesses and/or conditions ? (give details)
Section 1 rarely chew your food thoroughly eat on the move or at your desk whilst working burning sensations in your stomach indigestion take indigestion tablets difficulty digesting fatty foods offensive smelling wind bad breath IBS (section 1) nausea (section 1) stomach upsets/pains white coated tongue gall bladder problems piles/haemorrhoids anal irritation constipation diarrhoea (section 1) strain to pass stool painful to pass blood in/on stool mucus in/on stool stools float stools smell offensive feel full after eating a meal flatulence/bloating/belching shortly after eating excessive/offensive wind hours after eating crohn’s disease coeliac disease colitis (sections 1) diverticulitis antibiotics in the last year prolonged course of antibiotics in your lifetime thrush (section 1) cystitis (section 1) athlete’s foot/fungal toenails sugar cravings anal irritation bloating (sections 1) ‘brain fog’ or difficulty concentrating bouts of diarrhoea fatigue (sections 1) high sugar diet teeth grinding onset of digestive problems after travelling regularly eat sushi or rare meats history of food poisoning how many bowel movements per day?
Section 2 need to eat frequently without food: irritability / dizziness / sweating experience drowsiness or fatigue during the day need coffee, tea or cigarettes in the morning need more than 8 hours sleep per night slow to wake up in the morning excessive sweating excessive thirst mood swings anxiety (section 2) energy dips – highs and lows loss of concentration cravings for sweet or starchy foods craving for alcohol avoid exercise due to tiredness
Section 3 light headedness when stand up quickly become easily irritated or unable to cope deteriorating memory function poor concentration low energy levels low sex drive insomnia (section 3) weight gain muscle weakness tremors, numbness or restless legs depression (sections 3) palpitations (sections 3) poor skin regeneration low appetite experience of a major personal loss experience of a major shock or traum
Section 4 weight gain difficulty losing weight excessively tired and sluggish feel the cold cold hands and feet depressed (section 4) easily upset low sex drive high cholesterol difficulty swallowing pills infertility (section 4) weak nails (section 4) constipation (section 4) anaemia (section 4) thinning hair dry coarse hair cracked skin on heels thinning eyebrows slow to wake up dry skin (section 4) history of miscarriages low blood pressure early menopause goitre (section 4) irregular heartbeat intolerant of heat nervousness (section 4) hyper-activity (section 4) weight loss or failure to gain weight difficulty maintaining weight high appetite (section 4) protruding eyeballs
Section 5 family history of allergies coeliac as a baby glue ear as a child bed wetting as a child rhinitis (section 5) seasonal allergies ME/chronic fatigue fibromyalgia (section 5) lack of energy palpitations (section 5) acne (section 5) ear infections cystitis (section 5) digestive problems bloating (section 5) weight gain sinusitis (section 5) anxiety or paranoia fluid retention skin rashes (section 5) mood swings asthma (section 5) eczema (section 5) headache/migraine hay fever (section 5) arthritis (section 5) nasal congestion or phlegm cough need to breathe through mouth dark circles under eyes puffy eyes (section 5) excessive swelling from insect bites
Section 6 difficulty shaking off infections recurrent /prone to thrush recurrent / prone to cystitis frequent use of antibiotics swelling/ tenderness: neck, groin or armpit cold sores (section 6) bleeding gums boils or styes poor wound healing more than one cold a year - how many?
Section 7 take regular exercise have blood pressure above 140/90 a resting pulse above 75 beats per min. weigh < 14lb (7 kg) over your ideal weight have a history of heart disease in family eat meat and/or cheese < 3 times a week What kind of exercise do you take? How many times do you exercise per week? Smoke - how many per day average? Drink alcohol - how many drinks per week average?
Section 8 sunbathe excessively or use sunbeds spend a lot of time in traffic exercise by busy roads drink alcohol daily have metal (mercury) fillings/amalgams drink unfiltered tap water generally eat non-organic food work with chemicals e.g. paints/ solvents use regular household cleaning products
Section 9 - MEN ONLY mood swings or depression loss of motivation and drive loss of libido impotence/problem maintaining erection problems with reproductive organs e.g. testes frequent urination or difficulty urinating male pattern baldness skin problems low sperm count poor sperm morphology (quality) undescended testes sexually transmitted disease Do you have a sexually transmitted disease? – state which
Section 10 - WOMEN ONLY are your periods regular are your periods light are your periods irregular are your periods moderate are your periods heavy are your periods contain clots are your periods suffer from PMS How many days before period do you suffer PMS? How many days after period do you suffer PMS? Date of last period How frequent are your periods (days)? How long do your periods last (days)? PMS symptoms: mood swings anxiety/panic irritability (section 10) anger (section 10) frustration (section 10) sugar cravings headaches (section 10) increased appetite low energy (section 10) tearfulness (section 10) depression (section 10) confusion (section 10) poor sleep (section 10) lethargy (section 10) weight gain (section 10) bloating (section 10) breast pain swelling of feet/hands PCO (section 10) PCOS (section 10) endometriosis fibroids (section 10) fibrocystic breasts osteoporosis thrush (section 10) abnormal smear test sexually transmitted disease Do you have a sexually transmitted disease? – state which hot flushes or night sweats low libido (section 10) depression (section 10) taking/taken HRT Ovary/ovaries removed – when? Hysterectomy – when? currently pregnant trying to become pregnant length of time trying to conceive current contraception: pill current contraception: rhythm current contraception: barrier current contraception: injection current contraception: coil current contraception: none current contraception: sterilised type of pill: mixed type of pill: oestrogen type of pill: progesterone type of coil: copper type of coil: hormonal Miscarriage - how many? Termination - how many?
How many times a day do you eat/drink the following:
raw fruit
raw vegetables/salad
cooked vegetables
slices of wholemeal bread/bread rolls/bagels etc
slices of white bread/bread rolls/bagels/croissants etc
glasses of water - bottled/filtered/tap
fruit juice - state type
milk - state type
coffee - state type
tea - state type
how many teaspoons of sugar do you add to drinks/food
How many times a week do you eat/drink the following:
red meat - beef/lamb/pork/sausage/ham/bacon
game - venison/rabbit/pheasant/partridge
poultry - chicken/turkey
oily fish - salmon/mackerel/sardines/herring/tuna/trout
white fish - cod/halibut/plaice/swordfish etc
shellfish - prawns/mussels/scallops/clams etc
soya products - tofu/soya milk/soya yoghurt etc
pulses/beans - chickpeas/lentils/baked/kidney beans etc
natural live yoghurt
cheese
eggs
fresh nuts - almond/brazil/pecan/cashew/walnut/hazelnut etc
seeds - linseeds/sunflower/pumpkin/sesame/hemp etc
wholegrain rice/quinoa/ millet or barley
wholegrain pasta
white rice
white pasta or couscous
dried fruit
fried foods - crisps/chips/samosa/fry -up
flame-grilled or barbequed food
ready meals/ready -made sauces
tinned food -- state type
puddings - ice cream/mousses/sorbet/sponges/pies etc
snacks - cakes/biscuits/cereal bars/flapjacks etc
snacks - crisps/twiglets/tortilla/salted nuts/bombay mix etc
confectionary/sweets/chocolate
glasses of alcohol - state which
eat out - restaurants/cafes etc
takeaways
Postcode - state usual choice
do you usually add salt to cooking and/or food (yes - no)
currently vegetarian since
previously vegetarian, dates: from to
currently vegan since
do you/have you suffered from binge eating/anorexia nervosa/bulimia ? from to
any foods you particularly dislike ?
any foods or drinks you would find hard to give up?
If you have any other information your therapist should know prior to the consultation, please contact her.
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NU Boost Health is a nutritional health company based in Edinburgh. I create individual nutrition programmes that could help you have more energy, improved digestion, better mood, a healthier weight and fewer negative health symptoms.
