Nutrition Programme Questionnaire |
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Name: |
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Age: |
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Address: |
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Post Code: |
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Telephone Number: |
Home: Work: |
Occupation: |
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D.O.B. |
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Weight (without clothes) |
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Height (without shoes): |
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Health profile Please make a list of the health problems you would like to clear up and indicate how long you have had these problems. e.g. Headaches 5 years |
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Health problem |
Duration |
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. |
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What medication do you take for these? |
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Under what circumstances do these problems improve? |
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Under what circumstances do they get worse? |
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What other illnesses have you had in the last 10 years ? |
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What operations have you had? |
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What is your normal blood pressure?(don't worry if you don't know) |
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| What is your resting pulse rate per minute? | |
To take your pulse you should be sitting down, relaxed and calm when you take your pulse.
Your Pulse can be found inside the bony protuberance on the thumb side of your wrist.
Count the number of beats in 60 seconds.
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Nutrition Programme Questionnaire cont. Heredity profile |
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Do you have children? If so state age and sex |
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Do they suffer any particular illness? |
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How many brothers and sisters do you have? state age and sex |
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What illness is/was your father prone to? |
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What illness is/was your mother prone to? |
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Cardiovascular profile |
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Is your blood pressure above 140/90? |
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Is your pulse after 15mins rest above 75? |
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Are you more than 14lbs (7kgs) over your ideal weight? |
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Do you smoke more than 5 cigarettes a day? |
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Do you do less than 2 hours exercise a week? |
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| Do you eat more than one spoon of sugar a day? | |
Do you eat out more than five times a week ? |
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| 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 |
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| Do you take exercise that noticeably raises your heart beat more than 3 times a week? | |
| Does your job involve vigorous activity? | |
| Do you regularly play a sport? (football, squash etc.) | |
| Do you have any physically tiring hobbies? (gardening, etc.) | |
| Do you consider yourself fit? |
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Pollution risk Profile |
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| 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 busy roads? | |
| Do you smoke more than 5 cigarettes a day? | |
| Do you live or work in a smoky atmosphere? |
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| Do you buy foods exposed to exhaust fumes? | |
| Do you generally eat non-organic produce? | |
| Do you drink more than one unit or ounce 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 |
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| 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? |
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| Do you work harder than most people? | |
| Do you become easily 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 |
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| 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, food or drinks containing sugar or cigarettes at regular intervals during the day? | |
| Do you often feel drowsy during the day? |
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| Do you get dizzy or irritable if you don't eat often? | |
| Do you avoid exercise due to tiredness? | |
| Do you sweat a lot or get excessively thirsty? | |
| Is your energy less now than it used to be? | |
Digestion Profile |
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| Do you chew your food thoroughly? | |
| Do you sometimes suffer form 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? |
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| Do you occasionally use indigestion 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 |
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| Do you get more than 3 colds a year? | |
| Do you find it hard to shift an infection (cold or otherwise)? | |
| Are you prone to thrush or cystitis? | |
| Do you often take anti-biotic's more than twice a year? | |
| Is there a history of cancer in your family? |
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| Have you ever had any growth or lump biopsies? | |
| Do you have any inflammatory diseases such as eczema, asthma or arthritis? | |
| Do you suffer from hay fever? | |
| Do you suffer from allergy problems? | |
| Have you had a major personal loss in the past year? | |
Histamine Profile Underline the following that apply to you |
| Sleep over eight 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 or fingers, tends towards depression, don't put on weight, poor tolerance of pain. |
Allergy Profile |
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Do you suffer from any of the following? please underline. Nasal problems, eczema, dermatitis, asthma, migraine, irritable bowel syndrome, frequent bloatedness, facial puffiness. |
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| Do you have any allergies? If so what? | |
| State type of reaction | |
| have they been tested? | |
| What food or drinks would be hard to give up? |
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Additional questions for women only |
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| Are you pregnant, if so haw many weeks? | |
| Are you trying to become pregnant? | |
| Have you ever had a miscarriage? | |
| Do you have an IUD fitted, or use birth control pills? state which | |
| Are you periods regular? |
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| Are you post menopausal? | |
| Do you suffer from any pre menstrual bloatedness, tiredness, irritability, depression, breast tenderness, headaches (please underline) | |
| Any other symptoms. | |
Diet Analysis |
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| Please tick the questions to which you would answer 'yes' or fill in the 'number of times ' you eat the food referred top in the question. | |
| Were you breast fed? | |
| 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? | |
| How many teaspoons of sugar do you add to food/drinks each day? |
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| Do you use salt in your cooking? | |
| Do you add salt to your food/. | |
| How many coffees 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? |
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| Do you normally eat white rice or flour? | |
| How many cans of food do you eat per week? | |
| How many slices of bread or roll do you eat each week? | |
| How many pints of milk do you drink in a week> | |
| How many times in 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 bottled water instead of tap water? | |
| Do you frequently eat in stressful conditions or on the move? | |
| Does your job involve eating out a lot? | |
| How would you describe your appetite? | a.poor b. average. c. good |
Write down all the foods and drinks consumed over the next 2 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. |
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| DAY ONE | |
| Breakfast | |
| Lunch | |
| Dinner | |
| Snacks/drinks |
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| DAY TWO | |
| Breakfast | |
| Lunch | |
| Dinner | |
| Snacks/drinks | |
Are these two days representative of your usual eating habits? If not, what is a more usual day |
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| USUAL DAY | |
| Breakfast | |
| Lunch | |
| Dinner | |
| Snacks/drinks |
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What nutritional supplements do you take daily on a regular basis? |
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SYMPTOM ANALYSIS |
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Each question in this section starts with a list of symptoms associated with nutrirional deficiency. Underline the conditions you often suffer from. Some symptoms are repeated. Please underline them in all cases.
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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 Varicose veins Loss of muscle tone Infertility
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 Orritability Poor concentration 'Prickly' legs Poor memory Stomach pains Consti[ation Tingling hands Rapid heart beat
Burning or gritty eyes Sensitivity to bright light sore tongue Cataracts Dull or oily hair Eczema or dermatitis Split naails Cracked lips |
Lack of energy Diarrhoea Insomnia Headaches or migranes Poor memory Anxiety or tension Depression Irritability Bleeding or tender gums Acne
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
Infrequent dream recall Water retention Tingling hands Depression and nervousness Irritability Muscle tremors or cramps Lack of energy Flaky skin
Poor hair condition Eczema or dermititis Mouth oversensitive 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 Infertility
Muscle cramps or tremors Insomnia or nervousness Joint pain or arthritis Tooth decay High blood pressure
Muscle tremors or spasms Muscle weakness 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
Poor sense of taste or smell White marks on more than two finger nails Frequent infections Stretch marks Acne or greasy skin Low fertility Pale skin Tendency to depression Poor appetite
Muscle twitches Childhood growing pains Dizziness or poor sense of balance Fits or convulsions Sore knees
Family history of cancer Signs of premature ageing Cataracts High blood pressure Frequent infections
Excessive or cold sweats Dizziness or irritability after 6 hours without food Need for frequent meals Cold hands Need for excessive sleeep or drowsiness during the day Excessive thirst 'Addicted' to sweet foods |