First Name:___________________________ Last Name: ____________________
Address:_______________________________________________________________
_______________________________________________________________________
_____________________________________ Post Code: _____________________
email address: _______________________________________________________
Telephone Number:(Work)___________________ (Home)_______________
Occupation: _______________________________________ Age:_________
What is your Weight (without clothes):________Stone
____lbs or _______kg
What is your Height (without shoes):__________feet ______
inches or ______cm
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
1________________________________________________ __________________
2________________________________________________ __________________
3________________________________________________ __________________
4________________________________________________ __________________
5________________________________________________ __________________
6________________________________________________ __________________
What medications (drugs) do you take for these? State 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?________________________________________
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? If so, state age and sex. _________________________
How many brothers and sisters do you have? State age and sex. ________________
Are there any particular illnesses that they suffer from? ___________________
What illness is/was your father prone to? __________________________________
What illness is/was your mother 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 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 yo regularly play 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 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?
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 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?
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 indegestion 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 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?
Histamine Profile
Underline the following that apply to you:
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? ____________
- State type of reaction. _____________________________________
- Have they been tested. _____________________________________
- What foods 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 bloatedness, tiredness,
irritability, depression, breast tenderness, headaches (Please underline)
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.
- ___ 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 cups of tea 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 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
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
