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    Nutritional Therapy Questionnaire

    Please provide details as fully and accurately as possible to enable the best assessment.

  • Thank you for completing the questionnaire.

    Saving and Submitting

    Only press the Green SUBMIT button when complete. OR SAVE the form (next to submit) to enable you to come back to it later. You will receive an email to the email you entered to access it.

    There are buttons at the start one in middle and one at the end. 

    Any problems or more to add after submission email me Marjorie at hello@nourishinsideout.co.uk

     

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  • Health Profile

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  • Medication

    Please list prescribed medication, self-prescribed medication (e.g. painkillers)
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  • Remedies

    Only include those you take regularly and want to continue. Please include brand and exact product name and dosage to enable interaction checking. Continuation is as my discretion. I cannot work alongside many herbal or homeopathic remedies due to unknown ingredients however include below.
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  • When did you last take antibiotics   Pick a Date   What were they for? How many courses of antibiotics in the last 5 years.      

  • Body Scan

    Please select all symptoms you experience regularly below for each section.
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  • Your vital statistics

  • What is your normal blood pressure?
    your resting pulse rate? 
    your current weight? 
    your height?
    your waist circumference? (if known)?
    your hip circumference? (if known)?
    your blood type? (if known)?
    Is your weight stable, increasing, or decreasing?
    Did you have the recommended immunizations as a child?             

  • Your family history

  • Your daily life

  • Do you enjoy your daily life?
    How many people depend on your support? 
    Do you feel supported by people around you? 
    Are you recently separated/divorced/a new parent?
    Are you recently bereaved?
    Have you moved house or changed jobs recently?
    Do you work long or irregular hours?
    Is your workload bigger than you can manage?
    Are you under significant stress in any other way?
    Do you feel guilty when you are relaxing? 
    Do you have a strong drive for achievement?
    Do you often do 2 or 3 tasks simultaneously?
    Do you take regular exercise?
    Is your job active? 
    Do you have any active hobbies?
    Do you sleep well?
    What do you do for relaxation?

  • Your digestion

    Do you regularly experience…

  • Indigestion (after food or between meals?)
    Indigestion after fatty food?
    Bowel movement shortly after eating? 
    Frequent stomach upsets or stomach pain?
    Nausea or vomiting?
    Pain between the shoulders or under the ribs?
    Constipation or hard-to-pass stools?
    Diarrhea or ‘urgency to go’?
    Blood or mucus in stools? 
    Undigested food in stools?
    Generally inconsistent bowel movements?
    Anal itching?
    Thrush or cystitis? 
    How often do you have a bowel movement?
    Have you noticed any recent change in bowel habit?   
                  
    Have you ever had a stomach upset after foreign travel?   

  • Your toxic exposure

  • Do you live, exercise or work in a city or by a busy road?
    Do you spend a lot of time on busy roads? 
    Do you live close to an agricultural area? 
    Do you drink unfiltered water?
    Do you drink alcohol?If so, how many units a week?
    What is your normal alcoholic drink?
    Do you smoke? If so, how many a day? 
    Do you live in a smoky atmosphere? 
    Do you think you may be addicted to anything?
    Do you spend a lot of time in front of a TV or VDU?
    Do you spend a lot of time on a mobile phone?
    Do you sunbathe a lot?
    Are you a frequent flyer?
    Are you exposed to chemicals through work or hobby?   
    Do you heat, freeze or wrap food in plastics?   
    Do you cook or wrap food in aluminium?   
    Do you regularly take antacid (indigestion) medication?   
    Roughly what percentage of your food is organic?  
    Do you frequently fry or roast food at high temperatures?  
    Do you regularly eat browned or barbecued foods?  
    Do you eat oily fish or shellfish more than 3 x a week?   
    Do you regularly consume artificial sweeteners?
    Do you floss your teeth regularly?
    Are your teeth filled with mercury amalgams?
     

  • Your energy levels

  • Do you need more than 8 hours sleep per night?
    Is your energy less than you want it to be?
    Do you find it difficult to get going in the morning? 
    Do you feel drowsy during the day?
    What time(s) of day is your energy lowest?
    Do you get dizzy or irritable if you don’t eat often?
    Do you use caffeine, sugar or nicotine to keep going?
    Do you fi nd it difficult to concentrate?
    Do you feel dizzy or light-headed if you stand up quickly?
    Do you suffer from unexplained fatigue or listlessness?

  • Women

  • Are you pregnant? ? If so, how many weeks?
    Are you trying to become pregnant?
    Are you breast-feeding at present?
    How many children have you had?
    Have you had problems with fertility?
    Have you ever had a miscarriage?
    What contraception do you use?
    Are you still menstruating?
    Are you or have you been on HRT?
    Are your periods regular?
    Any bleeding or spotting in between?
    Are your periods particularly heavy or painful?
    Do you suffer from PCOS, fibroids, endometriosis?
    Any known genito-urinary conditions?
    Are you happy with your sex drive?

  • Saving and Submitting

    Only press the Green SUBMIT button when complete. OR SAVE the form (next to submit) to enable you to come back to it later. You will receive an email to the email you entered to access it.

    Any problems or more to add after submission email me Marjorie at hello@nourishinsideout.co.uk

     

  • Menstruating Women:

  • Menopausal Women:

  • Men

  • Do you experience mood swings or depression?       
    Loss of sex drive?      
    Loss of motivation and drive?      
    Any known genito-urinary conditions?      
    Fertility problems?      
    Problems achieving or maintaining an erection?       
    Frequent or difficult urination?      
    Prostate problems?      
    Wake at night to urinate?      
    Difficult to start or stop urine stream?      
    Pain or burning when urinating?      

  • Eating Habits

  • Do you cater for a special diet in the household? 
    Who does the cooking in your household?
    Do you avoid any food for cultural/ethical reasons?
    Are you allergic to any foods?
    Do you suspect any foods don’t agree with you?
    Have you recently changed your diet?
    Do you eat on the move/when stressed?
    Do you ever have eating binges?
    What do you binge on? 
    Have you ever suffered from an eating disorder?
    Do you chew your food thoroughly?
    Are you excessively thirsty?

  • Your Health Carers

  • I have disclosed all the relevant information applicable to this nutrition  programme consultation and my health status at this point in time and will advice the Nutritional Therapist of any changes.

     

     

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  • As part of your healthcare:

    Nourish Inside Out may share your sensitive information with third parties to support your ongoing healthcare. If we do not receive this consent from you, we will not be able to coordinate your healthcare with that provided by other providers which means the healthcare provided by us may be less effective.

    We may also share your contact information with biochemical testing companies to order tests as part of your healthcare, some of which maybe from outside of the European Union. If we do not receive this consent from you, we will review alternative tests from providers based within the European Union.

    You can withdraw your consent to the above at any time by emailing hello@nourishinsideout.co.uk

  • Marketing & Information

    Nourish Inside Out would like to contact you by email with updates; health and nutrition  tips and resources, recipes and promotional offers, information on upcoming events and activities.

    You can withdraw your consent to the above communications at any time by clicking on the unsubscribe link at the bottom of the emails.

    Subscribe Here 

    Professional Development 

    Nourish Inside Out seeks to continuously improve our practice through professional development, a key part of which is sharing case histories with our peers through clinical supervision, online forums and discussion groups. Your name, address and contact details will never be shared.

    Nourish Inside Out may like to share your case history with peers for educational purposes. This could be through conferences, lectures, online forums, and publishing in medical journals, trade magazines or online professional sites. Your name, address and contact details will never be shared. 

    You can withdraw your consent to any of the above at any time by emailing Hello@nourishinsideout.co.uk

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  • 3 Day Lifestyle Diary

    Please choose 2 fairly typical week days and a weekend or ‘day off’. Record as much as you can about eating, sleep and leisure patterns. Please give as much information as possible - home-cooked or not, brand names, fresh, packaged, whole, refined, organic, etc. This helps your nutritional therapist build an accurate picture.
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  • Thank You For Taking Your Time To Fill The Form!

  • Saving and Submitting

    Only press the Green SUBMIT button when complete. OR SAVE the form (next to submit) to enable you to come back to it later. You will receive an email to the email you entered to access it.

    Any problems or more to add after submission email me Marjorie at hello@nourishinsideout.co.uk

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