Diet & Symptom Analysis

Private & Confidential

Name *
Name
Gender
Date of birth
Date of birth
Lifestyle risk factors
Current medications
Antibiotics history
Have you had surgery to remove gall-bladder, stomach or intestines?
WOMEN ONLY
Your Eating Habits (everyone)
Honesty is essential
per week
Portion= 100g/4oz. Include ham, sausages, salami, burgers, etc.
Portion= 100g/4oz. Chicken, turkey etc. Excludes fish.
Portion = 100g/4 oz excluding bones
Portion of cheese, yoghurt, milk pudding or glass of milk
Nuts, beans, lentils, soy products, mycoprotein etc.
Chips (fries), fried chicken and all items deep-fried in batter
Commercial microwave or freezer meals, TV dinners ready-to-heat pizzas etc.
Sweetened cereals, cake or sweet pastry, or 50 grams of sweet biscuits
Sweets, creamy sugary desserts, puddings, pies. Excludes fresh fruit.
Bar size approx 100 g or 3 oz
Olive, sunflower, safflower, groundnut/ peanut oil etc.
Portion size = about one tablespoon or amount in one sandwich
Portion size = about one tablespoon or amount in one sandwich
per day
About 300 ml, half a pint or one US cup
Including caffeinated and decaffeinated. Excludes herbal teas.
Total number added per day to drinks or cereal
Includes pills, granules and portions of “diet” products
(Per handful of pieces) in soup, salad, casseroles or served separately.
Whole-wheat, rye, oats (porridge etc), brown rice, cornflakes
White bread, white rice or pasta, croissants
Heavy use includes frequent consumption of salty or smoked foods
Please tick any symptoms below which seem particularly to apply to you in recent times
EYES
EARS
SKIN & FINGERNAILS
IMMUNE SYSTEM
MUSCLES
CIRCULATION
HORMONES
BRAIN & NERVOUS SYSTEM
BONES
MISCELLANEOUS
FOOD INTOLERANCE SYMPTOMS
DETOXIFICATION ISSUES
 

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