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
YesNo

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?
YesNo

If yes, state product, dose and duration

Supplements taken


Do you have any known allergies?
YesNo

If yes, state what and type of reaction


Have you been tested for allergies?
YesNo

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 thoroughlyeat on the move or at your desk whilst workingburning sensations in your stomachindigestiontake indigestion tabletsdifficulty digesting fatty foodsoffensive smelling windbad breathIBS (section 1)nausea (section 1)stomach upsets/painswhite coated tonguegall bladder problemspiles/haemorrhoidsanal irritationconstipationdiarrhoea (section 1)strain to pass stoolpainful to passblood in/on stoolmucus in/on stoolstools floatstools smell offensivefeel full after eating a mealflatulence/bloating/belching shortly after eatingexcessive/offensive wind hours after eatingcrohn’s diseasecoeliac diseasecolitis (sections 1)diverticulitisantibiotics in the last yearprolonged course of antibiotics in your lifetimethrush (section 1)cystitis (section 1)athlete’s foot/fungal toenailssugar cravingsanal irritationbloating (sections 1)‘brain fog’ or difficulty concentratingbouts of diarrhoeafatigue (sections 1)high sugar dietteeth grindingonset of digestive problems after travellingregularly eat sushi or rare meatshistory of food poisoning


how many bowel movements per day?

Section 2

need to eat frequentlywithout food: irritability / dizziness / sweatingexperience drowsiness or fatigue during the dayneed coffee, tea or cigarettes in the morningneed more than 8 hours sleep per nightslow to wake up in the morningexcessive sweatingexcessive thirstmood swingsanxiety (section 2)energy dips – highs and lowsloss of concentrationcravings for sweet or starchy foodscraving for alcoholavoid exercise due to tiredness

Section 3

light headedness when stand up quicklybecome easily irritated or unable to copedeteriorating memory functionpoor concentrationlow energy levelslow sex driveinsomnia (section 3)weight gainmuscle weaknesstremors, numbness or restless legsdepression (sections 3)palpitations (sections 3)poor skin regenerationlow appetiteexperience of a major personal lossexperience of a major shock or traum

Section 4

weight gaindifficulty losing weightexcessively tired and sluggishfeel the coldcold hands and feetdepressed (section 4)easily upsetlow sex drivehigh cholesteroldifficulty swallowing pillsinfertility (section 4)weak nails (section 4)constipation (section 4)anaemia (section 4)thinning hairdry coarse haircracked skin on heelsthinning eyebrowsslow to wake updry skin (section 4)history of miscarriageslow blood pressureearly menopausegoitre (section 4)irregular heartbeatintolerant of heatnervousness (section 4)hyper-activity (section 4)weight loss or failure to gain weightdifficulty maintaining weighthigh appetite (section 4)protruding eyeballs

Section 5

family history of allergiescoeliac as a babyglue ear as a childbed wetting as a childrhinitis (section 5)seasonal allergiesME/chronic fatiguefibromyalgia (section 5)lack of energypalpitations (section 5)acne (section 5)ear infectionscystitis (section 5)digestive problemsbloating (section 5)weight gainsinusitis (section 5)anxiety or paranoiafluid retentionskin rashes (section 5)mood swingsasthma (section 5)eczema (section 5)headache/migrainehay fever (section 5)arthritis (section 5)nasal congestion or phlegm coughneed to breathe through mouthdark circles under eyespuffy eyes (section 5)excessive swelling from insect bites

Section 6

difficulty shaking off infectionsrecurrent /prone to thrushrecurrent / prone to cystitisfrequent use of antibioticsswelling/ tenderness: neck, groin or armpitcold sores (section 6)bleeding gumsboils or styespoor wound healing


more than one cold a year - how many?

Section 7

take regular exercisehave blood pressure above 140/90a resting pulse above 75 beats per min.weigh < 14lb (7 kg) over your ideal weighthave a history of heart disease in familyeat 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 sunbedsspend a lot of time in trafficexercise by busy roadsdrink alcohol dailyhave metal (mercury) fillings/amalgamsdrink unfiltered tap watergenerally eat non-organic foodwork with chemicals e.g. paints/ solventsuse regular household cleaning products

Section 9 - MEN ONLY

mood swings or depressionloss of motivation and driveloss of libidoimpotence/problem maintaining erectionproblems with reproductive organs e.g. testesfrequent urination or difficulty urinatingmale pattern baldnessskin problemslow sperm countpoor sperm morphology (quality)undescended testessexually transmitted disease


Do you have a sexually transmitted disease? – state which

Section 10 - WOMEN ONLY

are your periods regularare your periods lightare your periods irregularare your periods moderateare your periods heavyare your periods contain clotsare 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 swingsanxiety/panicirritability (section 10)anger (section 10)frustration (section 10)sugar cravingsheadaches (section 10)increased appetitelow 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 painswelling of feet/handsPCO (section 10)PCOS (section 10)endometriosisfibroids (section 10)fibrocystic breastsosteoporosisthrush (section 10)abnormal smear testsexually transmitted disease


Do you have a sexually transmitted disease? – state which






hot flushes or night sweatslow libido (section 10)depression (section 10)taking/taken HRT


Ovary/ovaries removed – when?


Hysterectomy – when?






currently pregnanttrying to become pregnantlength of time trying to conceivecurrent contraception: pillcurrent contraception: rhythmcurrent contraception: barriercurrent contraception: injectioncurrent contraception: coilcurrent contraception: nonecurrent contraception: sterilisedtype of pill: mixedtype of pill: oestrogentype of pill: progesteronetype of coil: coppertype 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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