Questionnaire — Absolute Nutrition Therapy

Home Telephone Number

Mobile Number

Email Address

Age

DOB

Gender

Single/Married/Divorced/Widowed

Children?

Weight

Height

Occupation

Doctor Name

Doctor Address

Health Profile

Please make a list of all the health problems you would like to clear up, and indicate how long you have had these problems e.g. headaches 5 years

Under what circumstances do these symptoms improve?

Under what circumstances do they get worse?

What other forms of therapy, conventional, or alternative are you taking?

What other health problems, conditions or operations have you had in the past?

What medication, if any are you currently taking and what for?

What is the best thing that has happened to you in our life so far?

What is the worst thing that has happened to you in your life so far?

To what extent are you prepared to modify your lifestyle in order to improve your health?

What are the three most important benefits would you like to gain from this programme?

Drug Profile

Are you now, or have you in the past few years taken any of the following drugs? Please state approximately when, and for how long?

Antibiotics

Steroids

Tranquillisers

HRT

Birth control pills

Other drugs

Toxicity Profile

How many amalgam (dark silvery) fillings do you have?

Are you regularly exposed to busy traffic?

Are you regularly exposed to toxic substances, such as hair dye, nail varnish removers etc.

Do you smoke? If so how many per day?

How much alcohol do you drink per week?

Dietary and Lifestyle Questions

Please list any significant illnesses that members of your immediate family suffer/suffered from?

Do you know of any allergies/sensitivities you may have?

How stressful is your lifestyle?

Are you following any particular dietary programme?

Do you avoid purchasing food with?

Additives

Preservatives

Colourings

Do you add salt to your food?

Do you add sugar to your food?

How many cups of tea do you drink per day?

How many cups of coffee do you drink per day?

How much milk do you drink per day, including milk in drinks such as tea and coffee? Is it full, semi or skimmed? Organic?

How much water do you drink per day? Is it filtered, bottled or tap?

How often do you eat chocolate / sweets / biscuits?

How much bread do you eat per day? Is it white, wholemeal or brown?

How many times per week do you eat white meat? Type?

How many times per week do you eat red meat? Type?

How many times per week do you eat fish, please name type?

How many portions of fruit do you eat per day? State which

How many portions of vegetables / salads do you eat per day? Type?

What percentage of your fruit and veg are raw?

Do you take any nutritional supplements, such as Vitamin C or a Multivitamin? If yes, what brand do you use?

Do you take regular exercise? If yes, what type of exercise and how often?

Which foods would you have difficulty giving up?

Food Diary

Please write down all the foods, drinks and snacks you consume over a typical 4 day period. An accurate record of your food intake is required for nutritional analysis.

Breakfast - Day 1

Lunch - Day 1

Dinner - Day 1

Drinks / Snacks - Day 1

Breakfast - Day 2

Lunch - Day 2

Dinner - Day 2

Drinks / Snacks - Day 2

Breakfast - Day 3

Lunch - Day 3

Dinner - Day 3

Drinks / Snacks - Day 3

Breakfast - Day 4

Lunch - Day 4

Dinner - Day 4

Drinks / Snacks - Day 4

Symptoms Profile

For each of the following please answer the questions set below. Many of the questions are repeated throughout the analysis. For each of the following symptoms please enter;

0 - If you do not suffer from the symptom

1 - If you mildly or occasionally

2 - If you suffer severely or frequently

P - If you suffered in the past

A)

Frequent burping or belching after eating

Heartburn or acid stomach

Bloating or gassy stomach or abdominal pain

Flatulence

Bad breath

Constipation

Nausea

Diarrhoea

B)

Constipation

Stomach/abdominal bloating (excessive nasal mucus)

Frequent sore throats

Dark circles or bagginess under eyes

Lack of urination

Excess urination

Fluid retention

Pain in the liver area

Eczema psoriasis or skin problems

C)

Night or cold sweats

Dizziness, irritability, or fatigue if not eaten

Headaches

Sleepiness or drowsiness during the day

Mental confusion or poor concentration

Need for tea/coffee or something sweet to keep you going

D)

Receding gum line or loose teeth

Joint pain or inflammation

Muscle cramps, spasms, tremors or fatigue

Insomnia

Racing heart beat or missed extra beats

E)

Joint and or bone pain

Fluid retention

Fatigue particularly on waking

Insomnia

Itchy/greasy skin or dandruff

Sinus or chest problems

Frequent headaches

Aching or painful muscles

Heavy periods

F)

White marks on fingernails

Stretch marks

Reduced sense of taste or smell

Slow wound healing

Acne, greasy skin or other skin problems

Hair loss or dandruff

G)

Lack of enthusiasm for life

Frequent feeling of tiredness

Tiredness on waking

Exhaustion after mild exercise

H)

Anxiety

Irritability

Depression

Nervous or panic attacks

Mood swings

I)

Frequent colds

Frequent infections

J)

Poor circulation or sensitivity to cold

Dry mouth or lack of saliva

Dizziness or faintness when standing up

Water retention especially on walking

Rigid nails

Frequent colds or minor infections

K)

Easy weight gain

Ringing in the ears

Thick dry or scaly skin

Sensitivity to cold

Constipation

Frequent urination

L) IF APPLICABLE

Do any of the following symptoms increase before your period?

Mood swings

Anxiety or irritability

Weight gain or fluid retention

Fatigue

Headaches, dizziness or fainting

Depression

Forgetfulness or confusion

How did you hear about me?

Personal information will be treated in confidence and in accordance with the requirements of the Data Protection Act 1998. Occasionally there may be a temporary worsening of symptoms. This can be an indication that the healing process is taking place. On this understanding I confirm my wish to undergo this therapy treatment and agree to do so and to the best of my knowledge the information given by me is correct.

Electronic Signature

By checking YES, I can confirm that I have answered all questions honestly and that the information given is correct. I agree to share my form responses.