Nutritional Questionnaire by NU Boost Health

info@nu-boosthealth.co.uk | 07813 018 908

Nutrition & health questionnaire

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


Current health concerns

Please state any health concerns you would like help with and indicate how long you have had them:

Health Concern

Health Concern

Health Concern

Health Concern

Health Concern

Duration (months)

Duration (months)

Duration (months)

Duration (months)

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


Past Medical History

Have you undergone any operations ?
(give dates and condition)

What other illnesses have you had in the past ?
(give dates and condition)


Family medical history

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)


Symptoms analysis


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?


Dietary analysis

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.


Food diary

Date of Day 1

Breakfast
Lunch
Dinner
Snack
Drinks


Date of Day 2

Breakfast
Lunch
Dinner
Snack
Drinks


Date of Day 3

Breakfast
Lunch
Dinner
Snack
Drinks


Date of Day 4

Breakfast
Lunch
Dinner
Snack
Drinks

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