Preliminary questionnaire

1
Name or client number* This field is required
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2
Age
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3
Height
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4
Weight
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5
Waist measurement (at 1 inch above your belly button)
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6
Blood pressure (if known)
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7
Health concern 1 + medications* This field is requiredPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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8
Health concern 2 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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9
Health concern 3 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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10
Health concern 4 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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11
Health concern 5 + medicationsPlease describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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12
Any other medications or health concerns?
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13
Have you recently experienced persistent or regular pain in any of the following?
Head
Temples
Eyes
Abdomen
Chest
On passing urine
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14
If you ticked any of the preceding options, please provide more information
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15
Have you recently experienced blood in any of the following?
Sputum
Vomit
Urine
Stools
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16
If you ticked any of the preceding options, please provide more information
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17
Have you recently experienced changes in any of the following?
Mood (e.g. negative thoughts)
Thirst
Urination
Bowel habits
Skin/pallor
Vision
Breathing
Weight
Appetite
Body/face shape
Swallowing
Non-menstrual vaginal bleeding
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18
If you ticked any of the preceding options, please provide more information
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19
Supplement 1 Please give product name, manufacturer, dose and reason for taking
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20
Supplement 2 Please give product name, manufacturer, dose and reason for taking
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21
Supplement 3 Please give product name, manufacturer, dose and reason for taking
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22
Supplement 4 Please give product name, manufacturer, dose and reason for taking
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23
Supplement 5 Please give product name, manufacturer, dose and reason for taking
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24
Hospitalisations, accidents and serious or chronic illnessesPlease list all that you can remember with approximate dates
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25
Life events such as moving house/country, marriage/separation, bereavements, job changes/lossesPlease list all that you can remember with approximate dates
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26
Have you had any recent health tests? Please list any tests together with the results if you have them
Alternatively, email a copy of the results or bring them with you to the consultation
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27
How often do you eat each day (meals and snacks)?
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28
Where do you eat your meals?Tick all that apply
At a table
In front of the TV
At your desk
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29
What time is the first food of your day?
Hour
Minutes
AM
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30
What time do you have the last food of the day?
Hour
Minutes
AM
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31
Who does the cooking in your house?
You
Someone else
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32
Who does the food shopping in your house?
You
Someone else
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33
Do you have any food allergies or intolerances? (please give details)* This field is required
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34
Do you have any particular dietary requirements? (e.g., you are vegetarian, you hate cauliflower, you avoid pork)
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35
Do you smoke or vape?
Yes
No
Ex-smoker/vaper
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36
If you currently/used to smoke/vape please specify how many cigarettes/e-cigarretes per day and for how long you have smoked
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37
Do you drink alcohol?
Yes
No
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38
If you drink alcohol, tell me more about when you drink, what you drink and how much
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39
Do you use recreational drugs?
Yes
No
Ex-drug user
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40
If you use/have used recreational drugs please specify the drug used
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41
Do you currently exercise regularly?* This field is required
Yes
No
Not regularly, but sometimes
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42
What type(s) of exercise do you do?
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43
How many times a week?
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44
For how long do you exercise each time?
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45
What do you do to relax? And how often do you do it?* This field is required
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46
How stressed do you feel?Move the slider to indicate your stress level
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47
Tell me more about what stresses you
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48
How well do you sleep?Move the slider to indicate your sleep quality
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49
What time do you go to bed?
Hour
Minutes
AM
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50
What time do you wake up?
Hour
Minutes
AM
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51
How many hours of uninterrupted sleep do you get a night?
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52
The next section is for women onlyPlease hit skip to omit this section.
ContinueSkip
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53
Are you breastfeeding?
Yes
No
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54
Have your periods ever stopped for any reason other than pregnancy?
Yes
No
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55
Do you have regular periods?
Yes
No
Post-menopause
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56
Do you consider your periods to be heavy?
Yes
No
Previously heavy but not now because of menopause
Previously heavy but not now because taking contraceptive pill
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57
Have you ever had any miscarriages?
Yes
No
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58
Have you started the menopause?
Yes
No
Not sure
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59
If yes, please state when
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60
How many children have you given birth to, and what are their ages?
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61
Mother
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62
Father
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63
Maternal Grandmother
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64
Maternal Grandfather
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65
Paternal Grandmother
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66
Paternal Grandfather
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67
Sisters/brothers
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68
Children
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69
Digestion* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Reflux, heartburn, coughing after meals
Bloating
Diarrhoea
Constipation
Blood in stools
Fat or undigested food in stools
Parasites, anal itching
Piles
Gallstones
Nausea/vomiting, feeling of fullness
Belching, passing gas
Abdominal cramps
Food allergies/intolerances
Reflux, heartburn, coughing after meals
Bloating
Diarrhoea
Constipation
Blood in stools
Fat or undigested food in stools
Parasites, anal itching
Piles
Gallstones
Nausea/vomiting, feeling of fullness
Belching, passing gas
Abdominal cramps
Food allergies/intolerances
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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70
Energy* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent energy dips
Feel shaky after skipping a meal
Need to eat to keep up energy
Poor stamina, constantly tired
"Wired" feelings, restlessness
Feel cold, cold hands and feet
Frequent energy dips
Feel shaky after skipping a meal
Need to eat to keep up energy
Poor stamina, constantly tired
"Wired" feelings, restlessness
Feel cold, cold hands and feet
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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71
Appetite, weight* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Weight gain/overweight
Cravings, binge eating
Frequent dieting
Weight loss/underweight
Poor appetite
Water retention
Weight gain/overweight
Cravings, binge eating
Frequent dieting
Weight loss/underweight
Poor appetite
Water retention
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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72
Immunity* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent infections
Swollen glands/tonsilitis
Allergies (e.g., asthma, eczema, hay fever)
Auto-immune condition
Frequent infections
Swollen glands/tonsilitis
Allergies (e.g., asthma, eczema, hay fever)
Auto-immune condition
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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73
Head* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Headache, migraine
Faintness
Dizziness
Headache, migraine
Faintness
Dizziness
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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74
Mind, nervous system* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Poor memory
Word-finding difficulties
Difficulty concentrating, brain fog
Low mood, anxiety, personality changes
Obsessive, compulsive behaviours
Poor physical coordination, clumsy, tremors, slurred speech
Poor memory
Word-finding difficulties
Difficulty concentrating, brain fog
Low mood, anxiety, personality changes
Obsessive, compulsive behaviours
Poor physical coordination, clumsy, tremors, slurred speech
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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75
Nose, mouth throat* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Bleeding gums
Mouth ulcers
Cold sores
White coating on tongue, sore tongue
Stuffy nose
Sinus problems
Excessive mucus formation
Nose bleeds
Poor sense of smell
Sensitivity to smells
Chronic coughing
Bleeding gums
Mouth ulcers
Cold sores
White coating on tongue, sore tongue
Stuffy nose
Sinus problems
Excessive mucus formation
Nose bleeds
Poor sense of smell
Sensitivity to smells
Chronic coughing
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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76
Eyes, ears, skin, nails, hair* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Itchy skin, rashes
Easy bruising, slow wound healing
Brittle nails, white spots, ridges on nails
Hair loss, dry brittle hair
Excessive hair growth
Itchy, red, sore eyes
Itchy ears, earaches, ear infections
Ringing in ears
Hearing loss
Thinning eyebrows
Itchy skin, rashes
Easy bruising, slow wound healing
Brittle nails, white spots, ridges on nails
Hair loss, dry brittle hair
Excessive hair growth
Itchy, red, sore eyes
Itchy ears, earaches, ear infections
Ringing in ears
Hearing loss
Thinning eyebrows
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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77
Joints, bones, muscles* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Joint pain, stiffness
Sore, tender muscles
Arthritis
Back pain
Feeling of weakness in muscles
Loss of muscle mass
Osteoporosis
Joint pain, stiffness
Sore, tender muscles
Arthritis
Back pain
Feeling of weakness in muscles
Loss of muscle mass
Osteoporosis
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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78
Heart and circulation* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
High blood pressure
Low blood pressure, dizziness
Palpitations
Chest pain
Poor circulation
Pain in calves on walking
Anaemia
High blood pressure
Low blood pressure, dizziness
Palpitations
Chest pain
Poor circulation
Pain in calves on walking
Anaemia
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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79
Lungs* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Asthma, bronchitis
Chronic obstructive pulmonary disease
Shortness of breath, difficulty breathing
Asthma, bronchitis
Chronic obstructive pulmonary disease
Shortness of breath, difficulty breathing
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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80
Urinary tract* This field is requiredPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Frequent urination
Waking in night to urinate
Frothy, smelly urine
Urinary infections (cystitis)
Frequent urination
Waking in night to urinate
Frothy, smelly urine
Urinary infections (cystitis)
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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81
HormonesPlease rate each of the following symptoms
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Low thyroid function
Overactive thyroid
Painful or heavy periods
Menopause symptoms
Polycystic ovary syndrome
Infertility
Loss of libido/erectile dysfunction
Prostatic enlargement
Low thyroid function
Overactive thyroid
Painful or heavy periods
Menopause symptoms
Polycystic ovary syndrome
Infertility
Loss of libido/erectile dysfunction
Prostatic enlargement
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
Never/almost never
Occasional, not severe
Occasional, severe
Frequent, not severe
Frequent, severe
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82
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83
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