Health Check Questionnaire

All details will be held private & confidential

Click in the boxes to make your selections, and click at the start of each orange line to see the blue highlight which allows you to type text.

Personal Details
Title: Dr Full Name: Address: Mr Ms Mrs Miss Other:

Todays Date: Date of Birth: Height: Weight:

Postcode: Home Telephone Number: Work/Mobile Number:

Doctors Name & Address:

Doctors Telephone Number:

Postcode: Do you give permission for you GP to be contacted? Yes No Have you seen any other healthcare professionals regarding your symptoms including your GP? Yes What is/are your main reason(s) for seeking nutritional support? No Emergency Telephone Number:

How did you hear about ZNutrition?

Are you currently following a medically prescribed diet? Yes No

Are you currently undergoing any medical treatment? Yes No If yes: Please give details:

Are you pregnant or planning to become pregnant in the near future? Yes No

Do any of the following reduce your ability to achieve your health goals? Time Money Other: Page 1 of 8
ZNutrition 2011

Lifestyle

Motivation

Physical Well-Being

Emotional Well-Being

Knowledge

Medications & Supplements

Prescribed Drugs Medication e.g. simvastatin Dose 20mg Health Condition Being Treated/Reason high cholesterol Frequency 2 /day Duration 3 years Current Past

Over-the-Counter Medications Medication e.g. paracetemol Dose 2 tabs Health Condition Being Treated/Reason headache Frequency 2 /week Duration 6 months Current Past

Supplements It is helpful if you bring any supplements you are taking with you to the consultation Supplement e.g. vitamin C Dose 800mg Health Condition Being Treated/Reason immune system Frequency 1 /day Duration 1 year Current Past

Medical History Health Condition/Operation e.g. asthma Age of Onset age 1 & age 22 Duration 4 years Management/Treatment inhalers & diary-free diet

Page 2 of 8
ZNutrition 2011

Family History
Is there a history of health problems or disease in your family? Family Member
Mother

Condition

Family Member
Father

Condition

Maternal Grandmother

Paternal Grandmother

Maternal Grandfather

Paternal Grandfather

Aunt(s)

Uncle(s)

Female Cousin(s)

Male Cousin(s)

Sister(s)

Brother(s)

Niece(s)

Nephew(s)

Daughter(s)

Son(s)

Symptoms Please check all that apply

Potential Medical Referral
Unexplained Pain Paralysis Chest Pain Numbness Depression Bleeding From Nipple Persistent Cough Constipation Diarrhoea Blood in Urine

Vaginal Bleeding

Blood in Sputum Shortness of Breath

Persistent Nose Bleeds Vaginal Discharge Breast Lumps

Blood in Stool Slurred Speech

Difficulty Swallowing Blood in Vomit

Excessive Thirst

Unexplained Bruising Headaches

Blurred Vision

Dizziness Calf Swelling Loss of Appetite

Frequent Urination Unable to Gain Weight

Heavy Periods

Unexplained Loss of Periods Change in Appearance of Moles

Unexplained Rash

Unexplained Weight Loss

Weight, Sleep, & Mood

Fluctuating Weight Sudden Weight Gain Weight around Middle Difficulty Waking Up Un-refreshed After Sleep Wake Up In Night Hyperactive Lose Weight Easily Lost Weight Recently Weight on Hips & Thighs Difficulty Falling Asleep Gain Weight Easily Sudden Weight Loss Unhappy with Weight Asleep After Midnight Sleepy in the Day Insomniac Frustration

Gained Weight Recently Difficulty Losing Weight Disordered Sleep Pattern

Need More Than 8 Hours Aggression/Anger Anxiety

Need Less Than 7 Hours Stressed Depression

Irritable

Mood Swings

Page 3 of 8
ZNutrition 2011

Digestion
Fast Eater Bloating Cant Tolerate Fatty Meals Heartburn/Acid Reflux Frequent Hiccups

Pain Under Right Rib-Cage Abdominal Discomfort Anal Irritation

Pain Under Right Shoulder Blade Low Satiety after Eating Stools That Float Constipation

Pain Under Left Rib-Cage Diarrhoea Flatulence Haemorrhoids

Black Stools

Pus/Mucous in Stool

Frequent Foreign Travel

Parasite

Frequent Stomach Bugs

Energy, Inflammation, & Detoxification

Fatigue Asthma Conjunctivitis Eczema Hives Mastitis Prostatitis Urethritis Cellulite Exhaustion Cancer Fluctuating Energy Cardiovascular Disease Cystitis Hay Fever High Energy Frequent Injury Thrush Acne Boils Arthritis

Around Children Frequently Diverticulitis Hepatitis Labyrnthitis

Crohns Disease Gastritis IBS Nephritis Psoriasis Athletes Foot Gingivitis

Dermatitis

Herpes Virus (e.g. Cold Sore) Joint Pains Laryngitis

Frequent Colds/Infections Oesophagitis

Otis Media

Pancreatitis Sinusitis Lupus

Pelvic Inflammatory Disease Ulcers Gum Problems Caffeine Sensitive Night Sweats

Rhinitis/Frequent Runny Nose Amalgam/Metal Fillings Bad Breath

Caffeine Keeps You Awake

Headaches

Dark Circles Under Eyes

Dark Coloured Urine

Recreational Drugs Gall Bladder Problems

Exercise near Busy Roads

Feeling of a Hangover

Frequent Air Travel

High Exposure to Electrical Items Oily Fish 3+ Times per Week Strong Body Odour Rashes

High Exposure to Building Products Eat Mostly Non Organic Foods Sensitive to Chemicals

High Exposure to Pesticides Live in Highly Polluted Area Tinnitus Itching

Play Golf Regularly

Use Garden Chemicals

Yellow Discolouration in Skin/Eyes

Allergies & Intolerances

Family History of Allergy Been Tested for Allergies Itchy Eyes Sneezing Diagnosed Allergy Tested for Intolerances Tired After Eating History of Allergic Reaction Diagnosed Intolerance Swollen Lips Swollen Throat Carry an EpiPen Itchy Throat Foggy Brain

Please list any foods or chemicals that you react to:

Hormone Health - Women Only

Age of First Period: Lumpy Breasts Night Sweats Fibroids Low Sex Drive Labour Complications Endometriosis Age of Final Period (if applicable): PCOS Heavy Periods Light Periods Painful Periods Irregular Menses PMS

Menstrual Migraine/Nausea Menstrual Food Cravings Fertility Problems

Oral Contraceptive/Coil/Implant Hot Flushes Hair Loss

Menstrual Insomnia

Menstrual Change in Bowel Habits

Pregnancy Complications IVF/AssistedRT

Experienced Miscarriage/Still Birth

Difficulty Breastfeeding

Page 4 of 8
ZNutrition 2011

Hormone Health Men Only

Altered Urine Flow Fertility Problems Difficulty Passing Urine Erectile Dysfunction Prostrate Hyperplasia Premature Hair Loss Urinary Infrequency Low Sperm Count/Motility

Circulatory Health
Anaemia Vegetarian Vegan Angina High Blood Pressure Low Blood Pressure Muscle Cramps Cold Extremities

High Cholesterol

High Triglycerides

High LDL Cholesterol Atherosclerosis Nose Bleeds

Low HDL Cholesterol Blood Clotting Diabetes

Cardiovascular Disease Calf Pain Chest Pain

Arteriosclerosis Faint on Standing

Pain in Legs on Walking Palpitations

Shortness of Breath

Peripheral Vascular Disease

Thread Veins

Varicose Veins

Stress
Eat When Stressed Unhappy at Work Recently Separated Eat When Unhappy Unhappy at Home Recently Moved Reduced Appetite When Stressed Demanding Job Recently Married Feel Stressed Recently Divorced Anxious

Recently Changed Jobs

Recent Bereavement

Unique to You
Learning Difficulties Anorexia Bulimia Competitive Frequently Cold Low Attention Poor Memory History of Broken Bones Swollen Neck Often Thirsty

Frequently Hot Big Appetite Cracked Lips Morning Nausea Compulsive

Protruding Eyes Small Appetite

Premature Greying Dry Hair Dandruff Dry Skin

Exposed to Chemicals at Work Nails Break/Peel Easily Slow Healing

Red Pimples Tops of Arms Excessive Hair Growth High Tolerance To Cold

Stretch Marks

White Marks On Nails

Poor Sense Of Smell/Taste

Physical Activity
Very Active Active Quite Active Sedentary Enjoy Exercise Require Motivation

Type of Exercise

Frequency

Duration

Alcohol & Smoking

How many alcoholic drinks do you consume in a week? What type of alcohol do you usually consume? Do you currently smoke? Yes Have you ever smoked? Yes No No

How many cigarettes per day?

Page 5 of 8
ZNutrition 2011

Your Diet
Do you crave any foods? If so which? Do you dislike any foods? Which foods are your favourites? What special diet(s) are you/have you following/followed?

Per Week Food Item

Biscuits Cakes/Pastries Pints of Cows Milk Chocolate Red Meat (beef, pork, lamb) White Meat (chicken, turkey, game) Oily Fish White Fish Eggs Cheese Tomatoes Carrots Peas Berries Cauliflower, Broccoli, Cabbage Salads Pasta Pulses Nuts/Seeds

Per Day Quantity/Frequency Food Item

Slices of Bread Fruit Vegetables Decaf Coffee Coffee Caffeine/English Tea Herbal Tea Smoothie Squash Concentrated Juice Fresh Juice Tap Water Filtered Water Bottled Water Fizzy Drinks Diet Drinks Sport/Energy Drinks

Quantity/Frequency

Do you: Cook with vegetable oils? Add salt to your cooking? Mainly buy organic produce? Cater for a special diet? Cook with olive oil? Cook for more than one? Microwave food? Enjoy cooking? Eat ready prepared foods? Enjoy eating?

Wash & peel non organic produce? Eat out frequently?

Is food shopping easy for you? Regularly chew gum/sweets?

Frequent take-aways?

Avoid additives & preservatives?

Add sugar to food/drink?

Add artificial sweeteners to food/drink? Use margarines?

Frequently add ketchup/mayonnaise to meals? Regularly eat smoked/barbequed food? Were you: Breast fed? Raised on a healthy diet?

Eat white bread, pasta, & rice?

Choose low/reduced fat products?

A healthy eater in adolescence?

Have you: Recently changed your diet?

Page 6 of 8
ZNutrition 2011

Food Diary - Describe two typical weekdays and one typical weekend day.
Day Weekday 1 Time(s) Meal Breakfast Please Record Food/Drink Intake

Lunch

Dinner

Snacks

Drinks

Day Weekday 2

Time(s)

Meal Breakfast

Please Record Food/Drink Intake

Lunch

Dinner

Snacks

Drinks

Day Weekend Day

Time(s)

Meal Breakfast

Please Record Food/Drink Intake

Lunch

Dinner

Snacks

Drinks

Page 7 of 8
ZNutrition 2011

Additional Notes

Page 8 of 8
ZNutrition 2011