Health questionnaire - A Nourishing Notion

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Questionnaire

The following questionnaire is not designed to give a medical diagnosis.
It identifies your current strengths and risk factors, and highlights key areas of concern.
It also assists in uncovering the factors that may be contributing to your symptoms or current health concerns.

Please use this form if you are intending to, or have booked, an initial consultation with me.

Health Questionnaire

Personal Details

Date *

First Name *

Last Name *

Date of birth *

Phone *

Email *

General

What is the main reason(s) for seeking my assistance?

Do you have any allergies or intolerances? *

Yes (please detail)

No

Detail allergies or intolerances:

When did you last see your GP?

Are you on any regular medication? Please list: *

Do you take supplements? Please list. *

Do you have any diagnosed medical conditions? *

Have you ever had surgery? *

Yes (please provide details)

No

Surgery details

Do you have any significant family history? *

Are you pregnant or breastfeeding? *

Yes

No

Additional information

Do you smoke tobacco? *

Yes (please provide details)

No

How much tobacco do you smoke per day/week?

Do you use illicit drugs?

Yes

No

If yes, please provide details

Do you drink alcohol? *

Yes

No

If yes, how many standard drinks in one session?

Do you have 2 or more alcohol free days per week?

Yes

No

How many times do you drink alcohol per week?

Caffeine: do you drink coffee, black tea or energy drinks? *

Yes (please specify)

No

If you drink caffeine, how many drinks per day?

Do you suffer from headaches or migraines? *

Yes

No

Do you run hot or cold? *

Hot

Cold

Neither

Do you suffer from recurring infections or frequent illness? *

Yes

No

How would you describe your energy levels? *

Do you get "wired" or experience increased energy in the evening? *

How often do you go to the toilet at night? *

Do you have low or high blood pressure? *

Yes (please provide details)

No

Don't know

Blood pressure details

Do you have high cholesterol? *

Yes

No

Don't know

Do you eat when you don't feel physically hungry? *

Yes

No

Do you have cravings for any particular food, such as salt, sugar or alcohol? *

Do you snack after dinner or eat late at night? *

Yes

No

Is your weight of concern to you? *

Yes

No

Do you use conventional household cleaners and personal care products with synthetic fragrances (including home fragrances and scented candles etc)? *

Were you born vaginally or via caesarian section? *

Vaginally

Via caesarian section

Do you have any concerns regarding sexual function? *

Yes

No

Do you experience low libido? *

Yes

No

Do you spend much time outdoors in nature? *

Digestive Wellbeing

How often do your bowels open? *

Do you ever experience constipation or diarrhoea? If yes, please provide details: *

Do you "react" to any foods? *

Yes

No

Do you experience any reflux, pain, bloating or gas? *

Yes

No

Have you ever taken antibiotics? If so, how many times and when was the last time? *

Exercise

How many times a week do you exercise? For how long? *

Do you ever exercise to the point that you are breathing hard, and your heart rate is elevated? How often? *

Hydration

How much water (excluding caffeinated beverages) do you drink per day? *

What is your water quality like? Is it chlorinated of fluoridated? Rural? Filtered? *

Skin

Do you suffer from skin complaints? *

Mental and emotional wellbeing

Do you have a history of abuse, neglect, anxiety or depression, or other enduring mental illness? *

Do you feel socially connected in your life? *

Yes

No

Stress

Do you experience high amounts of stress in your day to day life? *

Yes

No

If yes, what are the main sources of stress?

Do you prioritise time for yourself? *

Yes

No

Do you consistently overcommit to things/people/activities in your life? *

Yes

No

Do you have difficulty setting boundaries with others? *

Yes

No

Do you have any stress reduction tools that you use on a regular basis (eg. meditation, tai chi, qi gong, yoga, deep breathing, music, journaling, spiritual or religious practices)? *

Sleep

What time do you go to sleep? *

What time do you wake up? *

On average, how many hours do you sleep for each night? *

Do you wake feeling refreshed? *

Yes

No

Do you have EMF emitting devices such as WIFI, cell phones, TV or Bluetooth in the bedroom at night? *

Yes

No

Do you have any pre-bedtime rituals? *

Reproductive Wellbeing (women)

Have you ever been on the oral contraceptive pill or other hormonal contraception?

Yes

No

If yes, how many years?

Do you know the length of your cycle? If yes, how many days typically?

Do you experience PMS (eg, bloating, cravings, irritability, breast tenderness) in the lead up to your period?

How many days does your period last for?

Is your period heavy?

Yes

No

Do you get period cramps?

Yes

No

Do you use pads, tampons or other?

Have you ever been pregnant?

Yes

No

Have you ever given birth (either vaginally or c-section)?

Yes

No

Do you have any pelvic floor concerns?

Additional Information

Is there anything else of relevance to your holistic wellbeing that you would like me to know?

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