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About
Nutritional Therapy
Family Health
Well-Being
Lifestyle
Blog
Contact
Diet & Symptom Analysis
Private & Confidential
Name
*
First Name
Last Name
Gender
Male
Female
Address
Telephone
Email Address
*
Physician’s name & address
Date of birth
MM
DD
YYYY
Weight
Height
Lifestyle risk factors
I work in a sealed building
I work with chemicals
I suffer chronic high stress levels
I rarely go outdoors
I rarely get any exercise
Daily smoking habits
0
1-10
10-20
20+
Amalgam (silver) tooth fillings
0
1-4
5-9
10+
Current medications
Beta-blockers
Contraceptive pill or HRT
Pain-killers
Anti-inflammatory steroids
Others (specify)
Other medications
Antibiotics history
Never taken
Occasional past use
Frequent past use
Long-term past use
Long-term current use
Have you had surgery to remove gall-bladder, stomach or intestines?
Yes
No
What illnesses run in the family?
Current health problems
What helps these problems?
Or makes them worse?
WOMEN ONLY
Number of pregnancies
0
1-2
3-4
5+
Are you pregnant now?
Breastfeeding?
Are you prone to miscarriages?
Your Eating Habits (everyone)
Honesty is essential
per week
Alcoholic drinks per week
0
1-3
4-7
8-14
15-21
22+
Portions of red meat per week
Portion= 100g/4oz. Include ham, sausages, salami, burgers, etc.
0
1-3
4-7
8+
Portions of white meat per week
Portion= 100g/4oz. Chicken, turkey etc. Excludes fish.
0
1-3
4-7
8+
Portions of fish or seafood per week
Portion = 100g/4 oz excluding bones
0
1-3
4-7
8+
Portions of dairy items per week
Portion of cheese, yoghurt, milk pudding or glass of milk
0
1-3
4-7
8+
Number of eggs per week
0
1-3
4-7
8+
Portions vegetable protein per week
Nuts, beans, lentils, soy products, mycoprotein etc.
0
1-3
4-7
8-14
15-21
22+
Portions deep-fried food per week
Chips (fries), fried chicken and all items deep-fried in batter
0
1-3
4-7
8-14
15+
Pre-cooked reheated meals/week
Commercial microwave or freezer meals, TV dinners ready-to-heat pizzas etc.
0
1-3
4-7
8-14
15+
Portions canned or instant food/week
0
1-3
4-7
8-14
15+
Sweet flour or cereal items/week
Sweetened cereals, cake or sweet pastry, or 50 grams of sweet biscuits
0
1-3
4-7
8-14
15+
Portions of ice cream per week
0
1-3
4-7
8-14
15+
Portions of other desserts/week
Sweets, creamy sugary desserts, puddings, pies. Excludes fresh fruit.
0
1-3
4-7
8-14
15+
Chocolate or candy bars/ week
Bar size approx 100 g or 3 oz
0
1-3
4-7
8-14
15+
Bags of crispy snacks per week
0
1-3
4-7
8-14
15+
Tbsps of oil per week
Olive, sunflower, safflower, groundnut/ peanut oil etc.
0
1-3
4-7
8+
Use of margarine per week
Portion size = about one tablespoon or amount in one sandwich
0
1-3
4-7
8-14
15+
Use of butter per week
Portion size = about one tablespoon or amount in one sandwich
0
1-3
4-7
8-14
15+
per day
Glasses of water per day
About 300 ml, half a pint or one US cup
0
1
2-3
4+
Soft drinks per day
0
1-2
3-4
5+
Cups of tea or coffee per day
Including caffeinated and decaffeinated. Excludes herbal teas.
0
1-3
4-6
7+
Spoons of sugar per day
Total number added per day to drinks or cereal
0
1-4
5-10
11+
Artificial sweeteners per day
Includes pills, granules and portions of “diet” products
0
1
2
3+
Portions fresh vegetables per day
(Per handful of pieces) in soup, salad, casseroles or served separately.
0
1-3
3-5
6+
Portions fresh fruit per day
0
1
2
3
4
Portions whole-grain items per day
Whole-wheat, rye, oats (porridge etc), brown rice, cornflakes
0
1
2
3
4
5
Portions white flour items per day
White bread, white rice or pasta, croissants
0
1
2
3
4
5
Salt consumption
Heavy use includes frequent consumption of salty or smoked foods
Light
Medium
Heavy
Please tick any symptoms below which seem particularly to apply to you in recent times
EYES
Focussing problem in bad light
Always sore, dry or bloodshot
Very sensitive to bright lights
EARS
Persistent itching in ears
Deafness
SKIN & FINGERNAILS
Spotty skin (acne)
Dry, flaky skin
Persistent dandruff
Pale skin
Itchy red patches
Eczema
Sore, raw tongue
Cracked lips
Sores that won’t heal
Split or brittle fingernails
White-spotted fingernails
Easy bruising
Burning sensations
IMMUNE SYSTEM
Frequent colds or infections
Persistent thrush (yeast infections)
MUSCLES
Cramps, twitching or spasms
Weakness
Pain
Muscles knotted—won’t relax
CIRCULATION
Tendency to high cholesterol
Irregular heartbeats
Palpitations
Sensitive to cold
Hot flushes
Bleeding gums
HORMONES
Premenstrual symptoms
Painful menstrual periods
Heavy periods
Absence of periods(before the menopause)
Breast tenderness
Enlarged prostate
Dizzy, shaky or headache if you miss a meal
Unexplained weight gain
BRAIN & NERVOUS SYSTEM
“Spaced-out” feeling
Deteriorating co-ordination
Deteriorating memory
Increasing confusion
Mood swings
Poor concentration
Tremors
Easily startled
Nervousness
Panic or anxiety attacks
Insomnia
Depression
Irritability
Psychiatric problems
Hyperactivity
BONES
Pain and tenderness
Brittleness (osteoporosis)
MISCELLANEOUS
Easy exhaustion
Breathlessness
Poor appetite
Poor sense of taste or smell
Constipation
Gall bladder problems
Great thirst
Heartburn
FOOD INTOLERANCE SYMPTOMS
Chronic fatigue or drowsiness
Head feels “foggy”
Sudden unprovoked aggression
Skin rashes
Frequent severe headaches
Chronic diarrhoea
Tummy griping or mucus discharge
Painful or tender joints
Frequently congested sinuses
Fluid retention
Chronic catarrh
Wheezing
Dark colour under eyes
Tummy discomfort gas & bloating
DETOXIFICATION ISSUES
Feels "hung-over" despite no alcohol
Often slightly nauseous
Psoriasis
Yellowish skin or eyes
Great lethargy
Bad reactions to chemicals
Unwell after coffee or a little alcohol
Tenderness under right-hand ribs
Premenstrual mood changes
History of breast or uterus cysts, tumours, fibroids, endometriosis
Ever abused drugs or alcohol?
Thank you!
© School of Modern Naturopathy
www.naturostudy.org