NUTRITION PROGRAMME QUESTIONNAIRE

PRIVATE AND CONFIDENTIAL

This questionnaire is designed to provide your nutritionist with all the information necessary to build you an individual nutritional
programme specifically tailored to your needs. Please answer the questions as accurately as you can.

First name:

Last name:

Address:

Post code:

E-mail:

Telephone number: (Work)

(Home)

Occupation:

Date of birth:

Your weight (without clothes):

Your height (without shoes):

Health Profile
Please make a list of all the health problems you would like to clear up, and indicate how long you have had these problems eg: Headaces 5 years
(Continue on a separate sheet if you need more space)

Health Problem

Duration

1
2
3
4
5
6
What medication (drugs) do you take for these (state daily dosage)
Under what circumstances do these problems improve?
Under what circumstances do they get worse?
What other illnesses have you had in the past ten years?
What operations have you had?
What is your normal blood pressure? (dont worry if you dont know)
What is your resting pulse rate per minute?
You should be sitting down, relaxed and calm when you take your pulse. Your pulse can be found inside the bony protuberance on the thumb side of your
wrist. Count the number of beats in 60 seconds.

Heredity Profile
Do you have any children? If so, state age and sex.

Are there any particular illnesses your siblings suffer from?

How many brothers and sisters do you have? State age and
sex.

What illness is/was your father prone to?

What illness is/was your mother prone to?

SYMPTOM ANALYSIS
This section lists symptoms associated with particular nutritional deficiencies. Tick the conditions you suffer from. You can
select conditions by pointing and clicking with your mouse at the grey tick boxes. Some symptoms are repeated. Please tick
them in all cases.
Mouth ulcers
Poor night vision
Acne
Frequent colds or infections
Dry flaky skin
Dandruff
Thrush or cystitis
Diarrhoea
Rheumatism or arthritis
Back ache
Tooth decay
Hair loss
Excessive sweating
Muscle cramps, or spasms
Joint pain or stiffness
Lack of energy
Lack of sex drive
Exhaustion after light exercise
Easy bruising
Slow wound healing
Varicose veins
Loss of muscle tone
Infertility
Frequent colds
Lack of energy
Frequent infections
Bleeding or tender gums
Easy bruising
Nose bleeds
Slow wound healing
Red pimples on skin
Tender muscles
Eye pain
Irritability
Poor concentration
Prickly legs
Poor memory
Stomach pains
Constipation
Tingling hands
Rapid heart beat
Burning or gritty eyes
Sensitivity to bright lights
Sore tongue
Cataracts
Dull or oily hair
Eczema or dermatitis
Split nails
Cracked lips
Lack of energy
Diarrhoea
Insomnia
Headaches or migraines
Poor memory
Anxiety or tension
Depression
Irritability
Bleeding or tender gums
Acne

Muscle tremors or cramps

Apathy
Poor concentration
Burning feet or tender heels
Nausea or vomiting
Lack of energy
Exhaustion after light exercise
Anxiety or tension
Teeth grinding

Muscle tremors or spasms

Muscle weakness
Insomnia or nervousness
High blood pressure
Irregular heart beat
Constipation
Fits or convulsions
Hyperactivity
Depression

Infrequent dream recall

Water retention
Tingling hands
Depression or nervousness
Irritability
Muscle tremors or cramps
Lack of energy
Flaky skin

Pale skin
Sore tongue
Fatigue or listlessness
Loss of appetite or nausea
Heavy periods or blood loss

Poor hair condition

Eczema or dermatitis
Mouth over sensitive to hot or cold
Irritability
Anxiety or tension
Lack of energy
Constipation
Tender or sore muscles
Pale skin
Eczema
Cracked lips
Prematurely greying hair
Anxiety or tension
Poor memory
Lack of energy
Poor appetite
Stomach pains
Depression
Dry skin
Poor hair condition
Prematurely greying hair
Tender or sore muscles
Poor appetite or nausea
Eczema or dermatitis
Dry, rough skin
Dry eyes
Frequent infections
Poor memory
Loss of hair or dandruff
Excessive thirst
Poor wound healing
PMS or breast pain
Infertility
Muscle cramps or tremors
Insomnia or nervousness
Joint pain or arthritis
Tooth decay
High blood pressure

Poor sense of taste or smell

White marks on more than
two finger nails
Frequent infections
Stretch marks
Acne or greasy skin
Low fertility
Pale skin
Tendency to depression
Poor appetite
Muscle twitches
Childhood growing pains
Dizziness or poor sense of
balance
Fits or convulsions
Sore knees
Family history of cancer
Signs or premature ageing
Cataracts
High blood pressure
Frequent infections
Excessive or cold sweats
Dizziness or irritability after 6
hours without food
Need for frequent meals
Cold hands
Need for excessive sleep or
drowsiness during the day
Excessive thirst
Addicted to sweet foods

LIFESTYLE ANALYSIS
Please answer Yes or No to the questions below.

Cardiovascular Profile
Is your blood pressure above 140/90?
Is your pulse after 15 minutes rest above 75?
Are you more than 14lbs (7kg) over your ideal weight?
Do you smoke more than 5 cigarettes a day?
Do you do less than two hours exercise a week?
Do you eat more than one spoon of sugar a day?
Do you eat meat more than 5 times a week?
Do you usually add salt to your food?
Do you have more than 2 alcoholic drinks a day?
Is there a history of heart disease in your family?

Exercise Profile
Do you take exercise that noticeably raises your
heart beat for 20 minutes more than 3 times a week?
Does your job involve vigorous activity?
Do you regularly play a sport? (football, squash etc.)
Do you have any physically tiring hobbies? (gardening etc.)
Do you consider yourself fit?

Pollution Risk Profile

Do you live in a city or by a busy road?
Do you spend more than 2 hours a week in traffic?
Do you exercise (jog, cycle, play sports) by busy roads?
Do you smoke more than 5 cigarettes a day?
Do you live or work in a smoky atmosphere?
Do you buy foods exposed to exhaust fumes?
Do you generally eat non-organic produce?
Do you drink more than 1 unit or oz of alcohol a day?
(1 glass wine, 1 pint of beer, or 1 measure of spirits)
Do you spend a lot of time in front of a TV or VDU?
Do you usually drink unfiltered tap water?

Stress Profile
Is your energy less now than it used to be?
Do you feel guilty when relaxing?
Do you have a persistent need for achievement?
Are you unclear about your goals in life?
Are you especially competitive?
Do you work harder than most people?
Do you easily become angry?
Do you often do 2 or 3 tasks simultaneously?
Do you get impatient if people or things hold you up?
Do you have difficulty getting to sleep?

Glucose Tolerance Profile

Do you need more than 8 hours sleep a night?
Are you rarely wide awake within 20 minutes of rising?
Do you need something to get you going in the morning,
like tea, coffee or a cigarette?
Do you have tea, coffee, sugar containing foods or drinks,
or cigarettes, at regular intervals during the day?
Do you often feel drowsy during the day?
Do you get dizzy or irritable if you dont eat often?
Do you avoid exercise due to tiredness?
Do you sweat a lot or get excessively thirsty?
Do you sometimes lose concentration?
Is your energy less now than it used to be?

Digestion Profile
Do you chew your food thoroughly?
Do you sometimes suffer from bad breath?
Are you prone to stomach upsets?
Do you often get a burning sensation in your stomach?
Do you find it difficult digesting fatty foods?
Do you occasionally use indigestion tablets?
Do you suffer from flatulence or bloating?
Do you experience anal irritation?
Do you have a bowel movement daily?

Immune Profile
Do you get more than three colds a year?
Do you find it hard to shift an infection (cold or otherwise)?
Are you prone to thrush or cystitis?
Do you often take antibiotics more than twice a year?
Is there a history of cancer in your family?
Have you ever had any growths or lumps biopsied?
Do you have an inflammatory disease such as eczema,
asthma or arthritis?
Do you suffer from hay fever?
Do you suffer from allergy problems?
Have you had a major personal loss in the last year?

Histamine Profile
Tick the following the apply to you:
Sleep over 8 hours
Much body hair
Sluggish metabolism
Short toes and fingers
Fat of well covered
Sleep less than 7 hours
Little body hair
Fast metabolism
Long toes and fingers
Dont put on weight

Little sex drive

Infrequent colds
Slow to wake up
Suspicious by nature
Can tolerate pain
Strong sex drive
Family history of allergies
Morning person
Tends towards depression
Poor tolerance of pain

Allergy Profile
Do you suffer from any of the following? Please tick
Nasal problems
Migraine
Hay fever
Irritable bowel syndrome
Eczema
Frequent bloatedness
Dermatitis
Facial puffiness
Asthma
Do you have any allergies?
If so, what?
State type of reaction?
Have you been tested?
What food or drinks would you find hard to give up?

Additional questions for Women Only

Are you pregnant? If so, how many weeks?
Are you trying to become pregnant?
Have you ever had a miscarriage?
Do you have an IUD fitted, or use the birth control pill?
State which?
Are your periods regular?
Are you post-menopausal?
Do you suffer from any pre-menstrual symptoms? (tick which ones)
Bloatedness
Tiredness
Irritability
Depression
Breast tenderness
Headaches

DIET ANALYSIS
Please answer Yes or No or indicate number of times you eat the food referred to in the question.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Were you breast fed?

Was a significant percentage of your diet as a child
high in fatty foods and sugar?
Do you go out of your way to avoid foods containing
preservatives or additives?
Do you avoid foods which contain sugar?
How many teaspoons or sugar do you add to
food/drinks each day?
Do you use salt in your cooking?
Do you add salt to your food?
How many coffees do you drink each day?
How many cups of tea do you drink each day?
How many times a week do you have meals
containing deep-fried food?
How many packets of instant or fast foods do
you eat each week?
How many times a week do you eat chocolate or
confectionary?
What percentage of your diet is raw fruit and
raw vegetables?

14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

Do you wash fruit and vegetables before eating?

Do you normally eat white rice or flour?
How many cans of food do you eat per week?
How many slices or bread or rolls do you eat
each week?
How many pints of milk do you drink in a week?
How many times a week do you eat red meat?
(beef, pork, lamb or game)
How many times a week do you eat white meat?
(poultry, fish)
What is your usual alcoholic drink?
How many glasses do you drink a week?
How many times a week do you eat live yoghurt?
Do you use a water filter or drink bottled water
instead of tap water?
Do you frequently eat under stressful conditions or
on the move?
Does your job involve eating out a lot?
How would you describe your appetite?
Poor
Average
Good

Write down all the foods and drinks consumed over the next two days, starting today.
Please add as much information as possible including quantities eaten, brand names,
and whether the food is fresh or packaged, refined or natural.

Day 1

Day 2

Breakfast

Breakfast

Lunch

Lunch

Dinner

Dinner

Snacks/Drinks

Snacks/Drinks

Day3

What nutritional supplements do you take daily on a regular

basis?

Breakfast

Lunch

Dinner

Snacks/Drinks

I hereby confirm that this information is correct to the best of my knowledge and that I am not withholding any important information.
Signed:

Date: