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Nutrition Programme Questionnaire

Name:
 
Age:
 
Address:
 
Post Code:
 

Telephone Number:

Home:                               Work:

Occupation:

 
D.O.B.
 
Weight (without clothes)
 
Height (without shoes):
 

Health profile

Please make a list of the health problems you would like to clear up and indicate how long you have had these problems. e.g. Headaches 5 years

Health problem
Duration
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 

What medication do you take for these?

Under what circumstances do these problems improve?
 
Under what circumstances do they get worse?
 
What other illnesses have you had in the last 10 years ?
 
What operations have you had?
 
What is your normal blood pressure?(don't worry if you don't know)
 
What is your resting pulse rate per minute?  

To take your pulse 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.

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Nutrition Programme Questionnaire cont. Heredity profile

Do you have children? If so state age and sex
 
Do they suffer any particular illness?
 
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?

 

 

 

Cardiovascular profile

Is your blood pressure above 140/90?
 
Is your pulse after 15mins rest above 75?
 
Are you more than 14lbs (7kgs) over your ideal weight?
 
Do you smoke more than 5 cigarettes a day?
 

Do you do less than 2 hours exercise a week?

 

Do you eat more than one spoon of sugar a day?  

Do you eat out more than five 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 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 (job, 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 one unit or ounce of alcohol a day? (1 glass of 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 become easily 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 a tea, coffee or cigarette?  
Do you have tea, coffee, food or drinks containing sugar or cigarettes at regular intervals during the day?  
Do you often feel drowsy during the day?

 

Do you get dizzy or irritable if you don't eat often?  
Do you avoid exercise due to tiredness?  
Do you sweat a lot or get excessively thirsty?  
Is your energy less now than it used to be?  

 

 

 

Digestion Profile

Do you chew your food thoroughly?  
Do you sometimes suffer form 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?  
Do your stools float?  

 

 

Immune Profile

Do you get more than 3 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 anti-biotic's more than twice a year?  
Is there a history of cancer in your family?

 

Have you ever had any growth or lump biopsies?  
Do you have any inflammatory diseases 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 past year?  

 

 

Histamine Profile

Underline the following that apply to you

Sleep over eight hours, little sex drive, much body hair, infrequent colds, sluggish metabolism, slow to wake up, short toes and fingers, suspicious by nature, fat or 'well covered', can tolerate pain, sleep less than 7 hours, strong sex drive, little body hair, family history of allergies, fast metabolism, 'morning person', long toes or fingers, tends towards depression, don't put on weight, poor tolerance of pain.

 

 

Allergy Profile

Do you suffer from any of the following? please underline.

Nasal problems, eczema, dermatitis, asthma, migraine, irritable bowel syndrome, frequent bloatedness, facial puffiness.

Do you have any allergies? If so what?  
State type of reaction  
have they been tested?  
What food or drinks would be hard to give up?

 

 

 

Additional questions for women only

Are you pregnant, if so haw many weeks?  
Are you trying to become pregnant?  
Have you ever had a miscarriage?  
Do you have an IUD fitted, or use birth control pills? state which  
Are you periods regular?

 

Are you post menopausal?  
Do you suffer from any pre menstrual bloatedness, tiredness, irritability, depression, breast tenderness, headaches (please underline)  
Any other symptoms.  

 

 

Diet Analysis

Please tick the questions to which you would answer 'yes' or fill in the 'number of times ' you eat the food referred top in the question.
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?  
How many teaspoons of 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 times a week do you have meals containing 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?  

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 of bread or roll do you eat each week?  
How many pints of milk do you drink in a week>  
How many times in 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 bottled water instead of tap water?  
Do you frequently eat in stressful conditions or on the move?  
Does your job involve eating out a lot?  
How would you describe your appetite? a.poor b. average. c. good

 

 

Write down all the foods and drinks consumed over the next 2 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 ONE
Breakfast  
Lunch  
Dinner  
Snacks/drinks

 

DAY TWO
Breakfast  
Lunch  
Dinner  
Snacks/drinks  
 

Are these two days representative of your usual eating habits? If not, what is a more usual day

USUAL DAY
Breakfast  
Lunch  
Dinner  
Snacks/drinks

 

What nutritional supplements do you take daily on a regular basis?

 
 

 

SYMPTOM ANALYSIS

Each question in this section starts with a list of symptoms associated with nutrirional deficiency. Underline the conditions you often suffer from. Some symptoms are repeated. Please underline 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 pains

Orritability

Poor concentration

'Prickly' legs

Poor memory

Stomach pains

Consti[ation

Tingling hands

Rapid heart beat

 

Burning or gritty eyes

Sensitivity to bright light

sore tongue

Cataracts

Dull or oily hair

Eczema or dermatitis

Split naails

Cracked lips

 

Lack of energy

Diarrhoea

Insomnia

Headaches or migranes

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

 

Infrequent dream recall

Water retention

Tingling hands

Depression and nervousness

Irritability

Muscle tremors or cramps

Lack of energy

Flaky skin

 

Poor hair condition

Eczema or dermititis

Mouth oversensitive 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

 

Muscle tremors or spasms

Muscle weakness

Insomnia or nervousness

High blood pressure

Irregular heart beat

Constipation

Fits or convulsions

Hyperactivity

Depression

 

Pale skin

Sore tongue

Fatigue or listlessness

Loss of appetite or nausea

Heavy periods or blood loss

 

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 of 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 sleeep or drowsiness during the day

Excessive thirst

'Addicted' to sweet foods