Nutritional Therapy Questionnaire

Please provide details as fully and accurately as possible.

First Name:		Last Name:
Work environment:		Email:
Telephone (Work):		Telephone (Home):
Date of birth:		Age:
Address:
Occupation:

Health profile

What is your main reason for seeking nutritional advice?
What outcome are you hoping to achieve?

What are the top 3 issues you would like to focus on?

	Health issue (e.g. arthritis, overweight)	Management so far (e.g. GP, operation, exercise, paracetamol etc.)	Onset/duration
1
2
3

Have you had any recent health tests? Please specify, if appropriate, and send copies through of recent results

Have you had any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any allergies, chronic or niggling health problems? (please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc.)

Do you suspect your symptoms relate to a particular event or time in your life?

Medication & Remedies

Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies.

Remedy	Dose	Condition being treated	Frequency & duration

Antibiotic history: please state when and why you last took antibiotics plus any previous times you can remember:

Body scan

Please tick any conditions that you regularly experience

Important symptoms:

Please indicate by ticking if you suffer from any of the following symptoms which may require additional medical care:

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 immunisations as a child?

Your family history

Do you have a family history of disease or allergies? (e.g. heart disease, diabetes, asthma, etc.) State disease, age at onset, gender.

Grandparents:
Parents:
Siblings:
Children:
Has anyone in your family experienced infertility?
(Female only) What age did you mother go through menopause?
(Male only) Have you ever had mumps?

Your digestion

Do you regularly experience…

How often do you have a bowel movement?
Do any foods cause digestive problems? (which ones?)

Your toxic exposure

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?
Roughly what percentage of your food is organic?

Your daily life

How many people depend on your support?
What do you do for relaxation?

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?
	Do you get dizzy or irritable if you don’t eat often?		Do you use caffeine, sugar or nicotine to keep going?
	Do you find it difficult to concentrate?		Do you feel dizzy or light-headed if you stand up quickly?
	Do you suffer from unexplained fatigue or listlessness?

What time(s) of day is your energy lowest?

Eating habits

Which are your favourite foods?
Which foods do you dislike?
Which foods do you crave?
Which foods would you find hard to give up?
Who does the cooking in your household?
Do you ever have eating binges? What do you binge on?
Have you ever suffered from an eating disorder? If yes, please give brief details.

	Do you cater for a special diet in the 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?
	Are you excessively thirsty?		Do you chew your food thoroughly?

Women only

Are you pregnant? If so, how many weeks?
How many children have you had?
What contraception do you use?

Menstruating Women: please check a box if you experience:

Menopausal Women: please check a box if you experience:

Men only

Your health carers

Is this your first visit to a Nutritional Therapist?
How did you find out about me?
What is your GP’s Name?
What is your GP’s Address?
What is your GP’s Phone?
Are any other therapists/clinics involved in your care?

Lifestyle diary

Please choose 2 fairly typical week days and a weekend or ‘day off’ and record as much as you can about your eating, sleep and leisure patterns on the page below. Please give as much information as possible – home cooked or not, brand names, fresh, packaged, whole, refined, organic etc. to help your nutritional therapist to build an accurate picture of your lifestyle. Please record your activity across 2 work or week days and 1 weekend/day off.

Diet	Week day 1	Week day 2	Day Off
Breakfast time
Breakfast description

Lunch time
Lunch description

Dinner time
Dinner description

Snack times
Snack descriptions

Coffees (sugars/cup)
“Normal” tea (sugars/cup)
Green/herbal teas
Fizzy drinks/cordials
Units of alcohol
Glasses of water
Other drinks

Routine	Week day 1	Week day 2	Day Off
Wake up time
Get up time
Work day start time
Work day breaks (total hours)
Work day end time
Time spent traveling
Time spent exercising
Type of exercise
Exercise time of day
Time spent relaxing
Type of relaxation
Other leisure activity
Other routine
Time spent outdoors
Energy low times
Overall mood
Go to bed time
Fall asleep time
Uninterrupted sleep?

Terms of engagement · Editor

The Nutritional Therapy Descriptor

Nutritional Therapy is the application of nutrition science in the promotion of health, peak performance and individual care. Nutritional therapy practitioners use a wide range of tools to assess and identify potential nutritional imbalances and understand how these may contribute to an individual’s symptoms and health concerns. This approach allows them to work with individuals to address nutritional balance and help support the body towards maintaining health. Nutritional therapy is recognised as a complementary medicine and is relevant for individuals with chronic conditions, as well as those looking for support to enhance their health and wellbeing.

Practitioners consider each individual to be unique and recommend personalised nutrition and lifestyle programmes rather than a ‘one size fits all’ approach. Practitioners never recommend nutritional therapy as a replacement for medical advice and always refer any client with ‘red flag’ signs or symptoms to their medical professional. They will also frequently work alongside a medical professional and will communicate with other healthcare professionals involved in the client’s care to explain any nutritional therapy programme that has been provided.

The Nutritional Therapist (NT) requests that the Client notes the following:

The degree of benefit obtainable from Nutritional Therapy may vary between clients with similar health problems and
following a similar Nutritional Therapy programme.
Nutritional advice will be tailored to support health conditions and/or health concerns identified and agreed between
both parties.
Nutritional therapists are not permitted to diagnose, or claim to treat, medical conditions.
Nutritional advice is not a substitute for professional medical advice and/or treatment.
Your Nutritional Therapist may recommend food supplements and/or functional testing as part of your Nutritional
Therapy programme and may receive a commission on these products or services.
Standards of professional practice in Nutritional Therapy are governed by the CNHC Code of Conduct.
This document only covers the practice of Nutritional Therapy within this consultation, and your practitioner will make it clear if he or she intends to step outside this boundary.

The Client understands and agrees to the following:

All consultations must be taken within 3 months of the initial consultation.
Please show up to our sessions free from distractions in a quiet space with good internet connection.
If you need to change or cancel or change your session please do so with a minimum of 48 hours notice. Sessions cancelled with less than 48 hours will result in you losing that session. If I need to change or cancel I will endeavour to do so within 48 hrs.
I am responsible for contacting my GP about any health concerns.
If I am receiving treatment from my GP, or any other medical provider, I should tell him/her about any nutritional strategy provided by my nutritional therapist. This is necessary because of any possible reaction between medication and the nutritional programme.
It is important that I tell my nutritional therapist about any medical diagnosis, medication, herbal medicine, or food
supplements, I am taking as this may affect the nutritional programme.
If I am unclear about the agreed nutritional therapy programme/food supplement doses/time period, I should contact my nutritional therapist promptly for clarification.
I understand that the advice is personal to me and may not be appropriate for others.
I must contact my nutritional therapist should I wish to continue any specified supplement programme for longer than the original agreed period, to avoid any potential adverse reactions.
Recording consultations using any form of electronic media is not allowed without the written permission of both me and my Nutritional Therapist.
This agreement is subject to English law with the exclusive jurisdiction of the courts of England and Wales.

We understand the above and agree that our professional relationship will be based on the content of this
document. We declare that all the information we share during this professional relationship is confidential and to the best of our knowledge, true and correct.

Consent

We 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. Please tick the appropriate boxes to confirm your consent:

	I consent to my sensitive information being shared with other healthcare providers, whose details I have provided
	I consent to my sensitive information being shared with my GP if appropriate

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. Please tick the box to confirm your consent:

I consent to my contact information being shared with biochemical testing companies outside of the European Union

We would like to contact you occasionally by email with promotional offers, information on upcoming events and activities, and newsletters. Please tick the appropriate box to confirm your consent to be contacted for these purposes:

	I would like to receive regular newsletters
	I would like to receive promotional offers and information on upcoming events and activities

We seek 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. If you are happy for us to use your data for this purpose, please tick the box below to confirm your consent:

I consent to my data being used for the purpose of professional development

We would 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. I consent to my data being used for educational purposes. Please tick the appropriate box to confirm your consent:

Date · Editor 19 March 2024 Client Name · Editor Client Signature · Editor CLICK HERE TO DRAW Submit completed form Select this option if you are done filling in this form Save progress and submit later Select this option if you want to continue filling in this form later Continue

	Head		Mood
	Headaches		Please tick your predominant states – even if they conflict
	Migraine		Depressed
	Stiff neck		Anxious
	Fuzzy headed		Tense
	Dizziness		Angry
	Poor balance		Happy
	Pounding head		Aggressive
	Feeling of hangover		Balanced
	Unexplained pain		Optimistic
			Sad
	Hair		Pessimistic
	Oily		Tired
	Dry		Can’t be bothered
	Poor condition		Hyperactive
	Brittle		Cheerful
	Thinning		Agitated
	Premature grey		Easily upset
	Dandruff		Tearful
	Increased facial hair		Jittery
	Increased body hair		Frightened
	Decreased body hair		Explosive
			Pent up
	Mouth		Worried
	Sore tongue		Irritated
	White / red patches		Annoyed
	Tooth decay		Overwhelmed
	Ulcers		Suicidal
	Bad breath		Fluctuating
	Sore throats		Aggressive
	Poor sense of taste
	Excess saliva		Mind
	Dry mouth		Forgetful
	Difficult swallowing		Difficulty learning new things
	Hoarse voice		Easily confused
	Gingivitis		Can’t switch off
	Bleeding gums		Difficulty concentrating
	Cold sores		Easily frustrated
			Easily distracted
	Eyes		Difficult to make decisions
	Burning		Loss of interest in daily life
	Gritty		Fogginess
	Protruding		Dyslexia
	Prone to infection		Dyspraxia
	Sticky		Insomnia
	Itchy		Hyperactive
	Painful		Panic attacks
	Poor night vision		No motivation
	Dry
	Cataracts		Chest
	Sensitive to light		Frequent colds and chest infections
	Bags		Asthma
	Swollen eyelids		Bronchitis
	Blurred vision		Palpitations
	Double vision		Heart condition
	Failing eye sight		Chest discomfort / pain
	Yellowish		Short of breath
			Difficulty breathing
	Ears		Wheezing
	Blocked		Persistent cough
	Sore		Noisy breathing
	Itchy		Breast pain
	Weeping
	Watery		Gut
	Overly waxy		Bloated
	Creased earlobe		Painful
			Tender
	Nose		Cramping
	Congested		Distended
	Runny		Nausea
	Frequent nose bleeds		Hiatus hernia
	Prone to snoring		Sensation of fullness
	Sinusitis		Acid reflux
	Hay fever		Heartburn
	Post-nasal drip		Flatulence
	Rhinitis		Belching
	Sneezing		Churning
	Poor sense of smell		Vomiting
			Irritable bowel
	Muscles		Coeliac
	Tender		Diverticula
	Sore		Polyps
	Cramps		Haemorrhoids
	Spasms		Ulcers
	Twitches		Sluggish
	Loss of tone		Sensitive
	Wasting		Constipation
	Weak		Diarrhoea
	Stiff
	Frozen		Genitals
	“Restless legs”		Itchy
	Numbness		Cystitis
			Thrush
	Skin		History of sexually transmitted disease
	Dry		Warts or Ulcers
	Rough		Herpes
	Flaky		Groin pain
	Scaly		Prostatitis
	Puffy		Pelvic inflammatory disease
	Pale		Impotence
	Brown patches		Painful intercourse
	Change in moles or lesions		Vaginal dryness
	Prematurely lined		Painful or frequent urination
	Congested		Unexplained discharge
	Oily
	Clammy		Hands
	Yellow		Dry
	Slow to heal		Cracked
			Eczema
	Skin prone to		Sore joints
	Acne		Puffy
	Pimples		Cold
	Rosacea		Chilblains
	Eczema		Numbness
	Dermatitis		Tingling
	Psoriasis		Feel clumsy & uncoordinated
	Rashes		Poor circulation
	Boils
	Hives		Nails
	Itching		Fragile
	Stretch marks		Dry
	Cellulite		Brittle
	Easy bruising		Flaky
	Thread veins		Peeling
	Varicose veins		Split
	Ringworm		Fungal
	Allergic reactions		Hangnails
	Excessive sweating		Infected
			Split cuticles
	Joints		Ridged
	Fingers, knees, back, shoulders etc.		Spoon shaped
	Painful		White spots on more than 2
	Inflamed		Horizontal white lines
	Swollen		Thickened or “horny”
	Stiff		Dark nails
	Rheumatic		Pail nail bed
	Arthritic
	Aching		Legs & feet
	Sore		Restless legs
	Difficulty bending		Swollen
	Reduced mobility		Aching
	Unsteadiness		Athlete’s foot
	Slow movement		Burning feet
			Tender heels
			Gout
			Sciatica
			Cold feet
			Tingling
			Numb
			Prickling

	Persistent or unexplained pain		Unexplained bleeding or discharge from nipple, vagina, or rectum
	Blood in sputum		Blood in vomit
	Blood in urine		Blood in stools
	Breast lumps		Calf swelling
	Difficulty swallowing		Excessive thirst
	Loss of appetite		Unexplained Bruising
	Rash or weight loss		Black tarry stools
	Increased urination		Inability to lose weight
	Slurred speech		Paralysis
	Painless ulcers or fissures		Bleeding in pregnancy

	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?		Diarrhoea or ‘urgency to go’?
	Blood or mucus in stools?		Undigested food in stools?
	Generally inconsistent bowel movements?		Anal itching?
	Thrush or cystitis?		Have you noticed any recent change in bowel habit?
	Are your stools pale, mid brown, dark brown, black, grey?		Have you ever had a stomach upset after foreign travel?

	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 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?
	Do you regularly eat browned or barbecued foods?		Do you frequently fry or roast food at high temperatures?
	Do you regularly consume artificial sweeteners?		Do you eat oily fish or shellfish more than 3 x a week?
	Are your teeth filled with mercury amalgams?		Do you floss your teeth regularly?
	Have you recently renovated your house?

	Do you enjoy your daily life?		Do you sleep well?
	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?

Nutritional Therapy Questionnaire

Wellbeing for Employers

Wellbeing for Employees

Support

Expertise

	Pre-menstrual bloating		Tiredness
	Irritability		Depression
	Breast tenderness		Water retention
	Headaches		Other

	Hot flushes		Insomnia
	Osteoporosis		Mood swings
	Depression		Vaginal dryness
	Other

	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

	Conferences		Lectures
	Online forums		Medical journals
	Trade magazines		Online professional sites
	Books