Nutrition Questionnaire Personal Information Title * Name * Last Name * Address * Postcode * Email * Telephone Date of Birth Children Yes No Current Weight Current Height Current body fat % (if known) Health Profile Please make a list of the health issues you would like to address and how long you have had them for: Health Issue Duration What is your blood pressure? What is your resting pulse? Do you have any children Yes No Do they suffer from any ailments? What illness is/was your father prone to? What illness is/was your mother prone to? Symptom Analysis Tick the following which apply to you and give more details below: Allergies Anxiety or Depression Arthritis or Rheumatism Asthma or breathing problems Bowel problems Cancer Diabetes Drug or Alcohol dependence Ear, Eye, Nose or Throat problems Eczema or skin conditions Epilepsy Heart conditions Hypertension Menstrual / Menopausal problems Osteoporosis Sleep problems Stomach Ulcers Thyroid problems Urinary tract conditions How long have you suffered with it for? Anything which triggers it? Digestive Problems: Do you suffer from any of the following: Indigestion Acid reflux Bloating after meals Stomach bloating Abdominal bloating Burning pains Stomach Throat Flatulence / Belching Constipation Frequent urging to stool Diarrhoea Diverticula Hemorrhoids Medications List any medications and dose: Medication Dose Lifestyle Analysis Sleep How many hours sleep do you get per night? Is it broken sleep? (i.e. waking and not being able to sleep again) Yes No Do you wake to urinate? Yes No Stress How would you rate your stress levels on a scale from 1 - 10 (1 = no stress, 10 = extremely stressed) 1 2 3 4 5 6 7 8 9 10 How do you manage your stress levels? Exercise How often do you excercise? More than once a day Once a day Every few days Once a week Once a month Less than once a month Never How long do you exercise for each time? 1 - 10 mins 10 - 30 mins 30 - 60 mins More than 1 hour What type of exercise do you do? Sport Cardio Weights Nutrition and Diet What supplements do you currently take? E.g. meal replacements, protein shakes. (Include dose and how often you take them): Tick any diets which apply to you: Vegetarian Vegan Calorie Restriction Pescatarian Have you undergone any allergy or intolerance testing? If yes, when and what were the results Indicate if you exclude any of the following: Dairy Eggs Soy Corn Wheat Gluten Red Meat Nuts Eating habits: (Tick if apply) Skip breakfast Graze (small meals throughout day) Regularly miss meals Eat constantly whether hungry or not Eat on the go How many cups do you drink per day? Water Or state in Litres Coffee Tea Herbal tea Fizzy drinks Alcohol How much sugar do you consume on a daily basis? (i.e. teaspoon of sugar in tea, or chocolate per day/week) Is there any further information you think could be relevant or useful please include below
