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Nutrition Questionnaire

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Form

Please provide details as fully and accurately as possible. If at any time
you need more space please continue on a separate sheet.

Work environment (e.g. city, farm)

Healthy Profile

Please list the issues you would like to focus on
Health issue (e.g. arthritis, overweight) | Management so far (e.g. GP, operation, exercise, paracetamol etc.) | Onset/duration
Have you had any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any allergies, chronic or niggling health problems? (please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc.)

Medication & Remedies

Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies. Continue on a separate sheet if necessary.

Body Scan

Please select any conditions that you regularly experience by clicking on the boxes

Your vital statistics

Your family history

Do you have a family history of disease or allergies? (e.g. heart disease,
diabetes, asthma, etc.) State disease, age at onset, gender

Your daily life

Your digestion

Do you regularly experience...

Your toxic exposure

Your energy levels

Women only

Men only

Eating Habits

Your Health Carers

Food Diary

Please choose 2 fairly typical week days and a weekend or ‘day off’ and record as much as you can about your eating, sleep and leisure patterns on the page below. Please give as much information as possible - home cooked or not, brand names, fresh, packaged, whole, refined, organic etc. to help your nutritional therapist to build an accurate picture of your lifestyle. Your Diet - please record your food intake across 2 work or week days and 1 weekend/day off.
Weekday 1
Weekday 2
Day Off

Your Routine

Your Routine - please do the same for your routine
Weekday 1
Weekday 2
Day Off

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BANT Member. British Association for Nutrition and Lifestyle Medicine
CNHC Registered. Complementary & Natural Healthcare Council. Professional Standards Authority Accredited Register.
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BANT Member. British Association for Nutrition and Lifestyle Medicine
CNHC Registered. Complementary & Natural Healthcare Council. Professional Standards Authority Accredited Register.
Facebook svgviewer-output-svg Instagram
Book An Appointment

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'As a Nutritional Therapist I can help you with all aspects of improving your health and wellbeing through optimal nutrition. However, I have a particular interest and passion for supporting people with autoimmunity, chronic ill health, gut health and skin conditions.'

Autoimmune Disease

Hashimoto’s Thyroiditis | Graves Disease | Coeliac Disease | Inflammatory Bowel Disease | Psoriasis | Rheumatoid Arthritis

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Gut Issues

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Irritable Bowel Syndrome

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Healthy Eating

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Weight Management

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Unexplained Fatigue, Low Energy

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Menopause

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