Henley Nutrition

This questionnaire is designed to gather all the informatin necessary to support your first consultation and build your individual nutritional programme. It covers each organ system and symptoms related to these systems. Many systems overlap and in some situations similar questions may be repeated to present an accurate assessment. Please allow up to an hour to complete this questionnaire. Time taken at this stage will enble more time to be focused, during your consultation, on your condition.

We look forward to discussing these results in more detail at your first consultation.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Post code

Phone Number

Area CodePhone Number

Email

example@example.com

Date of birth

Occupation

Your weight

Your height

Please list the health problem/s you would like to discuss, indicating how long you have had these problems, including relevant information; e.g. (1) Headaches, 5 years, bad in the mornings. When I have an upset stomach they get worse. (2) Stomach bloating and pain, for a long time, comes and goes.

What medications do you take for these? Please state dosage.

What is your current blood pressure? (only state if recently checked)

If you have children, please state their age/s and sex, indicating any illnesses they are prone to.

Please detail family illnesses; your siblings, parents and grandparents

Does your job involve eating out a lot?

It is important to assess the average level of nutrients consumed over a typical period. For this reason can you indicate the food and liquid taken each day over a 3 day period for : breakfast, lunch and dinner, including snacks and drinks.

DAY ONE, please include; breakfast, lunch and dinner with snacks and drinks including water.

DAY TWO, please include; breakfast, lunch and dinner with snacks and drinks including water.

DAY THREE, please include; breakfast, lunch and dinner with snacks and drinks including water.

Please list the nutritional supplements you take daily

The next sections ask you to click the button that best represents your answer to each question.

You can use your tab buttom to move from question to question and there is a submit button at the end of the final section.

1. Alcohol

2. Artificial sweeteners

3. Sweets, deserts and refined sugar

4. Carbonated drinks

5. Chewing tobacco

6. Cigarettes

7. Cigars or a pipe

8. Caffeinated drinks

9. Fast foods

10.Fried foods

11.Luncheon meats

12. Margarine

13. Milk

14. Radiation exposure (1 is no, 2 is yes - work: ie air crew)

15. Refined white flour and baked flour foods

16. Vitamins and minerals

17. Water, Distilled or filtered

18. Water, tap

19. Water, well or independent ground extraction

20. Diet often for weight control

21. Exercie per week

22. Changed jobs

23. Divorced

24. Work over 60 hours per week

Please indicate any medications you're taking or have taken in the last month

25. Antacids

26. Anti-anxiety medications

27. Antibiotics

28. Anticonvulsants

29. Antidepressants

30. Antifungals

31. Aspirin or ibuprofen

32. Asthma inhalers

33. Beta blockers

34. Birth control pills / implant contraceptives

35. Chemotherapy

36. Cholesterol lowering medications

37. Cortisone / steroids

38. Diabetic medications / insulin

39. Diuretics

40. Oestrogen or progesterone (pharmaceutical prescription)

41. Oestrogen or progesterone (natural)

42. Heart medications

43. High blood pressure medications

44. Laxatives

45. Recreational drugs

46. Relaxants / sleeping pills

47. Testosterone (natural or prescription)

48. Thyroid medication

49. Acetaminophen (Tylenol)

50. Ulcer medications

51. Viagra

52. Belching or gas within one hour after eating

53. Heartburn or acid re-flux

54. Bloating within one hour after eating

55. Vegan diet (no diary, meat, fish or eggs)

56. Bad breath (halitosis)

57. Loss of taste for meat

58. Sweat has a strong odor

59. Stomach upset by taking vitamins

60. Sense of excess fullness after meals

61. Feel like skipping breakfast

62. Feel better if you don't eat

63. Sleepy after meals

64. Fingernails chip, peel or break easily

65. Anemia, unresponsive to iron

66. Stomach pains or cramps

67. Diarrhoea, chronic (happened on and off for a long period of time)

68. Diarrhoea shortly after meals

69. Black or tarry coloured stools

70. Undigested food in stool

71. Pain between should blades

72. Stomach upset by greasy foods

73. Greasy or shiny stools

74. Nausea

75. Sea, car, air-plane or motion sickness

76. History of morning sickness

77. Light or clay coloured stools

78. Dry skin, itchy feet or skin peels on feet

79. Headache over eyes

80. Gallbladder attacks

81. Gallbladder removed

82. Bitter taste in mouth, especially after meals

83. Become sick if you were to drink wine

84. Easily intoxicated if you were to drink wine

85. Easily hungover if you were to drink wine

86. Alcohol per week

87. Recovering alcoholic

88. History of drug or alcohol abuse

89. History of hepatitis

90. Long term use of prescription or recreational drugs

91. Sensitive to chemicals (perfume, cleaning agents etc)

92. Sensitive to tobacco smoke

93. Exposure to diesel fumes

94. Pain under the right side of the rib cage

95. Haemorrhoids or varicose veins

96. NutraSweet (aspartame) consumption

97. Sensitive to NutraSweet (aspartame)

98. Chronic Fatigue or Fibromyalgia

99. Food allergies

100. Abdominal bloating 1 to 2 hours after eating

101. Are there specific foods that make you tired or bloated

102. Dose your pulse increase after eating

103. Do you suffer with airborne allergies

104. Do you experience hives

105. Do you experience sinus congestion

106. Do you crave bread or pasta

107. Do you suffer with alternating constipation and diarrhea

108. Crohn's disease

109. Do you have wheat or grain sensitivity

110. Do you have dairy sensitivity

111. Are there foods you could not give up

112. Do you have asthma, sinus infections and a stuffy nose

113. Do you experience bizarre vivid dreams and or nightmares

114. Do you use over-the-counter pain medication

115. Do you feel spacey or unreal

116. Anus itches

117. Coated tongue

118. Feel worse in mouldy or musty place

119. antibiotic for a total accumulated time of

120. Fungal or yeast infections

121. Ring worm, 'jock itch', 'athletes foot', or nail fungus

122. Yeast symptoms increase with sugar, starch or alcohol

123. Stools are hard or difficult to pass

124. History of parasites

125. Less than one bowel movement per day

126. Stools have corners or edges, are flat or ribbon shaped

127. Stools are not well formed (loose)

128. Irritable bowel or mucus colitis

129. Blood in stool

130. Mucus in stool

131. Excessive foul smelling lower bowel gas

132. Bad breath or strong body odours

133. Painful to press along outer sides of thighs

134. Cramping in lower abdominal region

135. Dark circles under eyes

136. History of carpal tunnel syndrome

137. History of lower right abdominal pains or ileocecal valve problems

138. History of stress fracture

139. Bone loss (reduced density on bone scan)

140. Are you shorter than you used to be?

141. Calf, foot or toe cramps at rest

142. Cold sores, fever blisters or herpes lesions

143. Frequent fevers

144. Frequent skin rashes and or hives

145. Herniated disc

146. Excessively flexible joints, 'double jointed'

147. Joints pop or click

148. Pain or swelling in joints

149. Bursitis or tendinitis

150. History of bone spurs

151. Morning stiffness

152. Nausea with vomiting

153. Crave chocolate

154. Feet have a strong odour

155. History of anaemia

156. Whites of eyes (sclera) blue tinted

157. Hoarseness

158. Difficulty swallowing

159. Feels like a lump in the throat

160. Dry mouth, eyes and/or nose

161. Gags easily

162. White spots on fingernails

163. Cuts heal slowly and or scar easily

164. Decreased sense of taste or smell

165. Experience pain relief with aspirin

166. Crave fatty or greasy foods

167. Low or reduced fat diet

168. Tension headaches at the base of the skull

169. Headaches when out in the hot sun

170. Sunburn easily or suffer sun-stroke symptoms

171. Muscles easily fatigued

172. Dry flaky skin or dandruff

173. Awaken a few hours after falling asleep, hard to get back to sleep

174. Crave sweets

175. . Binge or uncontrolled eating

176. Excessive appetite

177. Crave coffee or sugar in the afternoon

178. Sleepy in the afternoon

179. Fatigue that is relieved by eating

180. Headache if meals are skipped or delayed

181. Irritable before meals

182. Shaky if meals delayed

183. Family member with diabetes

184. Frequent thirst

185. Frequent urination

186. Muscles become easily fatigued

187. Feel exhausted or sore after moderate exercise

188. Vulnerable to insect bites

189. Loss of muscle tone, heaviness in arms/legs

190. Enlarged heart or congestive heart failure

191. Pulse below 65 per minute

192. Ringing in the ears (Tinnitus)

193. Numbness, tingling or itching in hands and feet

194. Depressed

195. Fear of impending doom

196. Worrier, apprehensive or anxious

197. Nervous or agitated

198. Feelings of insecurity

199. Heart races

200. Can hear heart beat on pillow at night

201. Whole body or limb jerk as falling asleep

202. Night sweats

203. Restless leg syndrome

204. Cracks at the corner of the mouth (Cheilosis)

205. Fragile skin, easily chaffed - as in shaving

206. Polyps or warts

207. MSG sensitivity

208. Wake up without remembering dreams

209. Small bumps on back of arms

210. Strong light at night irritates eyes

211. Nose bleeds and or tend to bruise easily

212. Bleeding gums especially when brushing teeth

213. Tend to be a 'night person'

214. Difficulty falling asleep

215. Slow starter in the morning

216. Tend to be keyed up, trouble calming down

217. Blood pressure above 120/80

218. Headache after exercising

219. Feeling wired or jittery after drinking coffee

220. Clench or grind teeth

221. Calm on the outside, troubled on the inside

222. Chronic low back pain, worse with fatigue

223. Become dizzy when standing up suddenly

224. Difficulty maintaining manipulative correction (chiropractor)

225. Pain after manipulative correction

226. Arthritic tendencies

227. Crave salty foods

228. Salt foods before tasting

229. Perspire easily

230. Chronic fatigue or get drowsy often

231. Afternoon yawning

232. Afternoon headaches

233. Asthma, wheezing or difficulty breathing

234. Pain on the inner side of the knee

235. Tendency to sprain ankles or 'shin splints'

236. Tendency to need sunglasses

237. Allergies and or hives

238. Weakness, dizziness

239. Height over 6'6''

240. Early sexual development (before age 10)

241. Increased libido

242. Splitting type of headache

243. Memory failing

244. Tolerate sugar, feel fine when eating sugar

245. Height under 4'10''

246. Decreased libido

247. Excessive thirst

248. Weight gain around hips or waist

249. Menstrual disorders

250. Delayed sexual development (after the age of 13)

251. Tendency to ulcers or colitis

252. Sensitive or allergic to iodine

253. Difficulty gaining weight, even with large appetite

254. Nervous, emotional, can't work under pressure

255. Inward trembling

256. Flush easily

257. Fast pulse at rest

258. Intolerance to high temperatures

259. Difficulty losing weight

260. Mentally sluggish, reduced initiative

261. Easily fatigued, sleepy during the day

262. Sensitive to cold, poor circulation (cold hands and feet)

263. Constipation, chronic - long term

264. Excessive hair loss and / or coarse hair

265. Morning headaches that wear off during the day

266. Loss of lateral 1/3 of eyebrows

267. Seasonal sadness

268. Prostate problems

269. Difficulty with urination, dribbling

270. Difficult to start and stop urine stream

271. Pain or burning with urination

272. Waking to urinate at night

273. Interruption of stream during urination

274. Pain on inside of legs or heels

275. Feeling of incomplete bowel evacuation

276. Decreased sexual function

277. Depression during periods

278. Mood swings associated with periods (PMS)

279. Crave chocolate around periods

280. Breast tenderness associated with cycle

281. Excessive menstrual flow

282. Scanty blood flow during periods

283. Occasional skipped periods

284. Variations in menstrual cycles

285. Endometriosis

286. Uterine fibroids

287. Breast fibroids, benign masses

288. Painful intercourse (dysparenia)

289. Vaginal discharge

290. Vaginal dryness

291. Vaginal itchiness

292. Gain weight around hips, thighs and buttocks

293. Excess facial or body hair

294. Hot flushes

295. Night sweats in menopausal females

296. Thinning skin

297. Aware of heavy and/or irregular breathing

298. Discomfort at high altitudes

299. 'Air hunger' or sigh frequently

300. Compelled to open windows in a closed room

301. Shortness of breath with moderate exertion

302. Ankles swell, especially at end of day

303. Cough at night

304. Blush or face turns red for no reason

305. Dull pain or tightness in chest and/or radiates into right arm, worse with exertion

306. Muscle cramps with exertion

307. Pain in the mid-back region

308. Puffy around the eyes, dark circles under eyes

309. History of kidney stones

310. Cloudy, bloody or darkened urine

311. Urine has a strong odour

312. Runny or drippy nose

313. Catch colds at the beginning of winter

314. Mucus producing cough

315. Frequent colds or flu

316. Never get sick

317. Other infections, sinus, ear, lung, skin, bladder, kidney, etc.

318. Acne (adult)

319. Itchy skin (Dermatitis)

320. Cysts, boils or rashes

321. History of Epstein Barr, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral conditions

Henley Nutrition

Diet Analysis

Diet

Lifestyle

Medications

Upper Gastrointestinal System

Liver and Gallbladder

Small Intestine

Large Intestine

Mineral Needs

Essential Fatty Acids

Sugar Handling

Vitamin Need

Adrenal

Pituitary

Thyroid

MEN ONLY

WOMEN ONLY

Cardiovascular

Kidney and Bladder

Immune system - well done this is the last section !!