Nutrition Therapist
Dian Shepperson Mills
Cert Ed B.A. Dip ION M.A.
dian@endometriosis.co.uk
A pdf version of this questionnaire is available, please click.
If you are using this questionnaire for an appointment with a nutritionist,
then please print it off and bring it with you to your consultation. For a postal/telephone
consultation then please print this document and send it with your cheque for £100 (UK pounds)
made payable to The Endometriosis and Fertility Clinic, (or Dian can now accept payment
by credit card) to
Dian Shepperson Mills Cert Ed B.A. Dip ION M.A.
Nutrition Therapist
The Endometriosis and Fertility Clinic
56 London Road
Hailsham
East Sussex
BN27 3DD
United Kingdom
Private and Confidential
This document is Private and Confidential and the information provided is
for the inclusive use of The Endometriosis and Fertility Clinic, Our commitment
to you is to provide the most appropriate treatment for your needs. This
questionnaire is designed to provide your nutritional therapist 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:____________________ Sex: M/F__
Address:__________________________________________________________________________
_________________________________________________________________________________
______________________________________________ Post
Code:_________________________
eMail:______________________________________________________
Telephone Number:(Work)_______________________
(Home)____________________ (mobile) ___________________
Occupation: _________________________________________
Date of Birth:_________________
What is your Weight (without clothes)
:_____________Stone _______lbs or __________kg.
Has your weight changed recently? ________
What is your Height (without shoes)
:_____________feet ________ inches or ________cm
If you have had other clinical test, then please bring relevant copies of those
results with you to the clinic.
How did you hear about the Endometriosis and Fertility Clinic? _______________
What other Complimentary Therapies have you tried? _____________________________________________
Which therapies did you find most helpful? _____________________________________________________
Doctor's Name: __________________________ Address: _____________________________________________
________________________________________________________________________________________________
Consultant's Name: __________________________ Address: _________________________________________
________________________________________________________________________________________________
Do you give permission for your medical Doctor's to be contacted? ____ Yes / No _____
Number of Doctor's seen: ____________________ Number of Consultants seen: ______________
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: Headaches 5
years (Continue on a separate sheet if you need more space)
Health problem and duration
1________________________________________________ __________________
2________________________________________________ __________________
3________________________________________________ __________________
4________________________________________________ __________________
5________________________________________________ __________________
6________________________________________________ __________________
What medications (drugs) do you take for these? State daily dose______________
What Nutritional Supplements do you take for these regularly? State product name, manufacturer, and daily dose.
______________________________________________________________________________________________
______________________________________________________________________________________________
Under what circumstances do these problems improve?______________________
Under what circumstances do they get worse?______________________________
What other illness have you had in the past ten years?___________________
What operations have you had (give dates)?________________________________________
What is your normal blood pressure? (don't worry if you don't 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 boney protuberance on the thumb side
of your wrist. Count the number of beats in 60 seconds.)
Heredity Profile
Do you have any children? | |
How many brothers and sisters do you have? |
|
|
|
What illness is/was your father prone to? __________________________________
What illness is/was your paternal grandfather prone to? __________________________________
What illness is/was your paternal grandmother prone to? __________________________________
What illness is/was your mother prone to? __________________________________
What illness is/was your maternal grandfather prone to? __________________________________
What illness is/was your maternal grandmother prone to? __________________________________
Symptom Analysis
Each question in this section starts with a list of symptoms associated with
nutritional deficiency. Tick the box by the conditions you often suffer from. Some symptoms
are repeated. Please underline them in all cases.
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 have a pain in your calves on walking?
- 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?
- Do you have tightness/chest pains?
- Do you have high cholesterol?
- Do you have high homocysteine?
- Do you have swollen ankles?
Exercise Profile
- Do you take exercise that noticeably raises your heart beat for 20 minutes
more than 3 times a week?
- Does taking exercise cause pain/exhaustion?
- Does your job involve vigorous activity?
- Do yo regularly play sport? (football, squash, etc)
- Do you have any physically tiring hobbies? (gardening, yoga, aerobics, etc)
- Do you consider yourself fit?
- Do you have an active job daily?
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 a busy road?
- 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 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?
- Do you have mercury fillings in your teeth?
Stress Profile
- Do you have low self esteem?
- Does stress make you feel exhausted?
- 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?
- Do you wake too early?
- Have you had a personal loss/trauma in the past year?
Respiratory Profile
- Do you cough at night?
- Do you suffer shortness of breath with exercise?
- Do you have recurrent chest infections or sinus problems?
- Do you work in a smoky environment?
- Do you wheeze?
Glucose Tolerance Profile
- Do you crave any particular foods? (name them) _______________________________________________
- 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, 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 don't eat often?
- Do yo 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?
Muscular/Skeletal Profile
- Do you have lower back pain?
- Do you have joint pain/stiffness?
- Do you have osteoporosis?
- Have you had bone fractures?
Digestion Profile
- Do you chew your food thoroughly?
- Do you sometimes suffer from bad breath?
- Are you prone to stomach upsets?
- Are you prone to piles?
- Do you often get a burning sensation in your stomach?
- Do you find it difficult digesting fatty foods?
- Do you occasionally use indegestion tablets?
- Which foods give you indigestion? ________________________
- Do you suffer from flatulence or bloating?
- Do you experience anal irritation?
- Do you have a bowel movement daily?
- Do your stools float?
- Do your stools contain blood, mucus, yellow and oily? Which ___________________
- Do you regularly suffer from diarrhoea? Linked with menstruation?
- Do you regularly suffer from constipation? Linked with Menstruation?
Pain Profile
- Is your pain:
- sharp, stabbing, lacerating, cutting, skewering
- hot, burning, intense, overwhelming
- wringing, twisting, taut, yanking
- deep ache, mild cramps, killer cramps
- excruciating, breathe taking, can't move
- just discumfort or mild twinges
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 cystitus?
- 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 hayfever?
- Do you suffer from allergy problems?
- Have you had a major personal loss in the last year?
Nervous System Profile
- Do you have fainting episodes?
- Do you go dizzy or loose your sense of balance?
- Do you have ringing in your ears?
- Have you ever had any seizure or epilepsy?
- Are you prone to depression/despair/low mood swings?
- Do you have any obsessions or feel overly suspicious?
- Do you have poor concentration or short memory?
- Do you have hot feet, cracked heels, teeth grinding?
Skin Profile
- Do you have dry skin?
- Do you have acne?
- Do you have eczema?
- Do you have psoriasis?
- Do you have flaky skin?
- Do you have greasy skin?
- Do you have dermatitis?
- Do you have boils?
- Do you have cysts?
- Do you have warts?
- Do you have verruca?
Weight Profile
-
- Do you have an inability to gain weight?
- Do you have an inability to lose weight?
- Is your weight static?
- Is your weight gain - central - back - hips/thighs?
- Do you have unexplained weight loss?
- Do you have unexplained weight gain?
Histamine Profile
Underline the following that apply to you:
Low | High |
Sleep over 8 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 and
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, hay fever, eczema, dermatitis, asthma, migraine,
irritable bowel syndrome, frequent bloatedness, facial puffiness.
- Do you have any allergies? _________ If so what? Food: ____________ Chemicals: _____________
- State type of reaction. _____________________________________
- Have they been tested. _____________________________________
- What foods or drinks would you find hard to give up? _________________________________________________________________
Additional Questions for Men Only
- Is your sperm count normal? ________________________
- Is your sperm motility normal? _____________________
- Is your erectile function normal? __________________
- Do you have difficulty urinating? __________________
- Does your urine flow weakly? _______________________
- Is your hair receding? _____________________________
- Is your hair prematurely grey? _____________________
Childhood illnesses
Please state: ______________________________________ _____________________________________________
Food dislikes: _____________________________________ _____________________________________________
Additional Questions for Women Only
- At what age did your periods begin? _______
- At what age did you take an OCP? __________
- Did you have any efects from the OCP? ________
- Are you pregnant? if so how many weeks?_______
- Are you trying to become pregnant?
- Have you ever had a miscarriage?
- Do you have an coil fitted, or use the birth control pill? State
which __________
- Are you post-menopausal?
- Have you had a hysterectomy?
- Have you had your ovaries removed?
- Have you ever taken HRT?
- If so then for how long? _________________
- Do you suffer from any pre-menstrual bloatedness, tiredness,
irritability, depression, breast tenderness, headaches (Please underline)
Period Profile
- Are your periods regular?
- Is your cycle 28 days? _______ Other: ____________
- Duration of bleed? ______days, light, heavy, flooding
- Colour of blood? red brown black - liquid tarry
- Are there clots (y/n)? ______
Endometriosis Profile
- Do you have abdominal pain?
- Do you have period pain?
- Do you have ovary pain?
- Do you have painful intercourse?
- Do you have mid cycle bleeding?
- Do you have heavy periods?
- Do you have ovarian cysts?
- Do you have adhesions?
PCOS Profile
- Do you have acne?
- Do you have irregular periods?
- Do you have hirsuitism (abnormal hair growth)?
- Do you have male pattern baldness?
- Do you have brown skin patches?
- Do you have weight gain on hips, thighs, stomache?
Obstetric Profile
- Have you had a miscarriage? ____
- Have you had IUI or IVF treatment? Dates: _____________________________
- Have you had complications in pregnancy?
- Have you had complications during labour?
- Have you had an abnormal smear result?
- Did you have a normal delivery?
- Did you breast feed?
Diet Analysis
Please tick the questions to which you would answer 'yes' or fill in the
'number of times' you eat the food referred to in the question.
- Are you vegan, vegetarian, picine vegstarion (Eats fish)?
- Were you breast feed?
- 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 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 cocoas 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 fried food? Deep fat / stir fries?
- What type of butter or margarine do you use?
- What type of cooking oil do you use?
- What type of salad dressing do you use?
- 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 rolls do you eat each week?
- How many pints of milk do you drink in a week?
- How much cheese do you eat weekly?
- 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 type of fish do you eat?
- Do you eat tofu or quorn?
- What is your usual alcoholic drink?_______________
- How many glasses do you drink a week?
- How many fizzy drinks do you drink each week?
- How many times a week do you eat live yoghurt?
- How many eggs do you eat in a week?
- 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?
- Do you eat in a café/restaurant more than three times a week?
- What foods do you avoid as they upset you?
- How would you describe your appetite?
- poor
- average
- good
Sample Diet
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
Breakfast
Lunch
Dinner
Snacks/Drinks
Day 2
Breakfast
Lunch
Dinner
Snacks/Drinks
Are these two days representative of your usual eating habits?
If not, what is a more usual day?
Breakfast
Lunch
Dinner
Snacks/Drinks
What Nutritional Supplements do you take daily on a regular basis?
Breakfast
Lunch
Dinner
Evening