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 complete this document and return it 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?
Child sex AgeIllness
   
   
   
 
Sex AgeIllness
   
   
   

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.

  • 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
  • Breast tenderness
  • Hot flushes
  • Varicose veins
  • Loss of muscle tone
  • Backache
  • Sub-fertility

  • 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
  • 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

  • Loss of hair colour
  • 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
  • Clumsiness.poor coordination

  • Low Blood Pressure / dizziness
  • Infrequent dream recall
  • Water retention
  • Tingling hands
  • Depression or nervousness
  • Irritability
  • PMS
  • Muscle tremors or cramps
  • Lack of energy
  • Flaky skin

  • 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
  • Sub-fertility

  • Muscle cramps or tremors
  • Insomnia or nervousness
  • Joint pain or arthritis
  • Tooth decay
  • High blood pressure
  • Muscle tremors or spasms
  • Osteoporosis

  • Muscle cramps or tremors
  • Muscle weakness
  • Osteoporosis
  • 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
  • Itchy legs
  • Pale inner eyelids
  • Difficulty swallowing

  • Poor sense of taste or smell
  • White marks on more than two finger nails
  • Frequent infections
  • Stretch marks
  • Acne or greasy skin
  • Sub-fertility
  • Pale skin
  • Tendency to depression
  • Poor appetite

  • Muscle twitches
  • Childhood 'growing pains'
  • Dizziness or poor sense of balance
  • Fits or convulsions
  • Sore knees
  • Sub-fertility

  • Family history of cancer
  • Signs of premature ageing
  • Cataracts
  • High blood pressure
  • Frequent infections
  • Dandruff

  • 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
  • High Cholesterol

  • lack of energy
  • Hair falling out
  • Difficulty swallowing
  • Weight gain
  • Constipation
  • Loss of 1/3 eyebrows
  • Loss of hearing
  • Feeling cold
  • Shaking hands

  • Low energy
  • Gum disease
  • Headaches
  • Insomnia
  • Irregular heartbeat
  • Heart disease

  • Osteoporosis
  • Inflammation
  • Osteoarthritis
  • Joint pains
  • Menopausal symptoms

  • Nervousness
  • Poor taste
  • Low energy


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:
    1. sharp, stabbing, lacerating, cutting, skewering
    2. hot, burning, intense, overwhelming
    3. wringing, twisting, taut, yanking
    4. deep ache, mild cramps, killer cramps
    5. excruciating, breathe taking, can't move
    6. 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.

  1. Are you vegan, vegetarian, picine vegstarion (Eats fish)?
  2. Were you breast feed?
  3. Was a significant percentage of your diet as a child high in fatty foods and sugar?
  4. Do you go out of your way to avoid foods containing preservatives or additives?
  5. Do you avoid foods which contain sugar?
  6. How many teaspoons of sugar do you add to food/drinks each day?
  7. Do you use salt in your cooking?
  8. Do you add salt to your food?
  9. How many coffees do you drink each day?
  10. How many cocoas do you drink each day?
  11. How many cups of tea do you drink each day?
  12. How many times a week do you have meals containing fried food? Deep fat / stir fries?
  13. What type of butter or margarine do you use?
  14. What type of cooking oil do you use?
  15. What type of salad dressing do you use?
  16. How many packets of 'instant' or fast foods do you eat each week?
  17. How many times a week do you eat chocolate or confectionary?
  18. What percentage of your diet is raw fruit and raw vegetables?
  19. Do you wash fruit and vegetables before eating?
  20. Do you normally eat white rice or flour?
  21. How many cans of food do you eat per week?
  22. How many slices of bread or rolls do you eat each week?
  23. How many pints of milk do you drink in a week?
  24. How much cheese do you eat weekly?
  25. How many times a week do you eat red meat? (beef, pork, lamb or game)
  26. How many times a week do you eat white meat? (poultry, fish)
  27. What type of fish do you eat?
  28. Do you eat tofu or quorn?
  29. What is your usual alcoholic drink?_______________
  30. How many glasses do you drink a week?
  31. How many fizzy drinks do you drink each week?
  32. How many times a week do you eat live yoghurt?
  33. How many eggs do you eat in a week?
  34. Do you use a water filter or drink bottled water instead of tap water?
  35. Do you frequently eat under stressful conditions or on the move?
  36. Does your job involve eating out a lot?
  37. Do you eat in a café/restaurant more than three times a week?
  38. What foods do you avoid as they upset you?
  39. How would you describe your appetite?
    1. poor
    2. average
    3. 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