nutritional health questionnaire

Your Personal Details
Name
First name* Last name*
Date of Birth

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Age
Sex
- male
- female
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
E-mail
Phone number
Occupation
Work environment

Your Health profile
What is your main reason for seeking nutritional advice?
What outcome are you hoping to achieve?
Please list the health problems you would like to focus on.
Health Problems e.g arthritis Management to date e.g. GP, operation, paracetamol, exercise, etc Onset Date Duration
Have you had any recent health tests? Please specify if appropriate
Have you had any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any 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.
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:
Please provide details as fully and accurately as possible.

health care providers
Is this your first visit to a Nutritional Therapist?
- Yes
- no
How did you find out about me?
GP’s Name
Phone
Address
Are any other therapists/clinics involved in your care?
- Yes
- no
Please list:
Signed*
Date*

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Disclaimer:

I have disclosed all the relevant information applicable to this consultation and my health status at this point in time. I consent for the information provided to be used by my Nutritional Therapist and for my therapist to liaise with appropriate health professionals should this be required.

I acknowledge that this is not designed to provide medical services nor is a health and nutrition consultation being provided as a substitute for a consultation, diagnosis, and treatment by a licensed primary health care professional, such as a Medical Doctor. Products or recommendations in this program are not intended to diagnose, prescribe, or treat symptom, defect, injury, or disease. The information provided is intended to inform, not provide individual medical advice.
*
- By submitting your details, you confirm that your data will be stored on this site

Your Personal Details

Health Problems e.g arthritis	Management to date e.g. GP, operation, paracetamol, exercise, etc	Onset Date	Duration

Remedy	Dose	Condition being treated	Frequency & duration