EatLiveLovefood's Functional Medicine Nutritional Questionnaire
This questionnaire has been designed to help us gain an understanding of your health concerns and to enable us to build you a uniquely tailored programme.
We will not share this information with anyone without your express permission. All information will be kept confidential.
*please allow 1 hour to fill in this form or download it above
* Required
What is your reason for wanting a consultation?
*
Your answer
Personal Information:
Title
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
Your answer
Age
*
Your answer
Address and City
*
Your answer
Post Code
*
Your answer
E-mail
*
Your answer
Phone numbers
*
Your answer
Occupation
*
Your answer
Work environment (e.g. city, farm, office, shift work)
*
Your answer
What is your preferred time of day for a consultation?
*
ie morning, afternoon or evening
Your answer
Health Vitals:
What is your normal blood pressure?
Your answer
What is your resting pulse rate?
Your answer
What is your current weight?
Your answer
What is your height?
Your answer
What is your waist circumference? (if known)
Your answer
What is your hip circumference? (if known)
Your answer
What is your blood type? (if known)
Your answer
Is your weight stable, increasing or decreasing?
Your answer
Did you have the normal immunisations as a child?
Your answer
Body Scan:
Please select all conditions that you REGULARLY experience, even if they conflict. (please ignore the asterisks as they are for internal use only)
Head:
Headaches*
Migraine
Stiff neck
Fuzzy head
Dizziness*
Poor balance
Pounding head
Feeling of hangover
Unexplained pain*
Hair:
Oily
Dry
Poor condition
Brittle
Thinning
Prematurely grey
Dandruff
Increased facial hair
Increased body hair
Decreased body hair
Mouth:
Sore tongue
Tooth decay
Mouth ulcers
Bad breath
Sore throat
Poor sense of taste
Excess saliva
Dry mouth
Difficulty swallowing*
Hoarse voice
Gingivitis
Bleeding gums
Cold sores
Eyes:
Burning
Gritty
Protruding
Prone to infection
Sticky
Itchy
Painful*
Poor night vision
Dry
Cataracts
Sensitive to light
Bags
Swollen eyelids
Blurred vision*
Double vision
Failing eyesight
Yellowish eyes
Ears:
Blocked
Sore
Itchy
Weeping
Watery
Overly waxy
Creased earlobe
Nose:
Stuffy
Congested
Runny
Frequent nose bleeds*
Prone to snoring
Sinusitis
Hay fever
Post-nasal drip
Rhinitis
Sneezing
Poor sense of smell
Muscles:
Tender
Sore
Cramps
Spasms
Twitches
Loss of tone
Wasting
Weak
Stiff
Frozen
Restless legs
Numbness
Skin:
Dry
Rough
Flaky
Scaly
Puffy
Pale
Brown patches
Changes in moles or lesions*
Prematurely lined
Congested
Oily
Clammy
Yellow
Skin prone to:
Acne
Pimples
Rosacea
Eczema
Dermatitis
Psoriasis
Rashes
Boils
Hives
Itching
Stretch marks
Cellulite
Easy bruising
Thread veins
Varicose veins
Ringworm
Allergic reactions
Excessive sweating
Joints (fingers, knees, back, shoulders, etc.)
Painful
Inflamed
Swollen
Stiff
Rheumatic
Arthritic
Aching
Sore
Difficulty bending
Reduced mobility
Unsteadiness
Slow movement
Mood:
Depressed*
Anxious
Tense
Angry
Happy
Balanced
Optimistic
Sad
Pessimistic
Tired
Can't be bothered
Hyperactive
Cheerful
Agitated
Easily upset
Tearful
Jittery
Frightened
Explosive
Pent up
Worried
Annoyed
Overwhelmed
Suicidal*
Fluctuating
Aggressive
Mind:
Forgetful
Difficulty learning new things
Easily confused
Difficulty concentrating
Easily frustrated
Easily distracted
Difficult to make decisions
Can't switch off
Loss of interest in daily life
Fogginess
Dyslexia
Dyspraxia
Hyperactive
Panic attacks
No motivation
Chest:
Frequent colds and chest infections
Asthma
Bronchitis
Diagnosed heart condition
Palpitations
Chest discomfort/pain*
Shortness of breath*
Difficulty breathing
Wheezing
Persistent cough*
Noisy breathing
Gut:
Bloated
Tender
Cramping
Distended
Nausea
Sensation of fullness
Acid reflux
Heartburn
Flatulence
Belching
Churning
Painful*
Irritable bowel syndrome
Coeliac
Hiatus hernia
Diverticula
Polyps
Haemorrhoids
Ulcers
Sluggish
Sensitive
Constipation*
Diarrhoea*
Genitals:
Itchy
Cystitis
Thrush
Ulcers
Warts
Herpes
Groin pain
Prostatitis
Pelvic inflammatory disease
Impotence
Painful intercourse
Vaginal dryness
Painful or frequent urination*
Unexplained discharge
Hands:
Dry
Cracked
Eczema
Sore joints
Puffy
Cold
Chilblains
Numbness*
Tingling
Feel clumsy and uncoordinated
Poor circulation
Nails:
Fragile
Dry
Brittle
Flaky
Peeling
Splitting
Hangnails (split cuticles)
Ridged
Spoon shaped
White spots on more than 2 nails
Horizontal white lines
Thickened or horny
Dark nails
Pale nail bed
Infected
Legs and Feet
Restless legs
Swollen
Aching
Athlete's foot
Fungal nails
Burning feet
Tender heels
Gout
Sciatica
Cold feet
Tingling
Numb*
Prickling
Menstruating Women:
Pre-menstrual bloating
Tiredness
Irritability
Depression
Breast tenderness
Water retention
Headaches
Other:
Menopausal Women:
Hot flushes
Insomnia
Osteoporosis
Mood swings
Depression
Vaginal dryness
Other:
Diet:
How often do you consume the following (Q 1-20):
*
0. Do not consume or use, 1. Consume or use 2-3 times monthly, 2. Consume or use weekly, 3. Consume or use daily
0
1
2
3
Alcohol
Artificial sweeteners
Candy, desserts, refined sugar
Carbonated beverages
Chewing tobacco
Cigarettes
Cigars and pipes
Caffeinated beverages
Fast foods
Fried foods
Sliced meats
Margarine and other spreads
Milk products
Radiation exposure (0=no, 1=yes)
Refined flours, baked goods
Vitamin and mineral supplements
Water, distilled
Water, tap
Water, well
0
1
2
3
Alcohol
Artificial sweeteners
Candy, desserts, refined sugar
Carbonated beverages
Chewing tobacco
Cigarettes
Cigars and pipes
Caffeinated beverages
Fast foods
Fried foods
Sliced meats
Margarine and other spreads
Milk products
Radiation exposure (0=no, 1=yes)
Refined flours, baked goods
Vitamin and mineral supplements
Water, distilled
Water, tap
Water, well
Lifestyle:
How often do you exercise? (Q 21)
*
Choose
0. Two or more times per week
1. One time per week
2. One or two times per month
3. Never, less than once a month
Have you recently changed your job? (Q 22)
*
Choose
0. More than twelve months ago
1. Within the last twelve months
2. Within the last six months
3. Within the last two months
Have you recently divorced or separated? (Q 23)
*
Choose
0. Never or more than two years ago
1. Within the last two years
2. Within the last year
3. Within the last six months
How frequently do you work 45 or more hours/week. (Q 24)
*
Choose
0. Never
1. Occasionally
2. Usually
3. Always
Medications:
Indicate any medications you are currently taking or have taken in the last month. (Q 25-51)
*
0. No, 1. Yes
0
1
Antacids
Anti-anxiety medications
Antibiotics
Anticonvulsants
Antidepressant
Antifungals
Aspirin/Ibuprofen
Asthma inhalers
Beta blockers
Birth control pills
Chemotherapy
Cholesterol lowering medications
Cortisone/Steroids
Diabetic medication/insulin
Diuretics
Estrogen or progesterone (prescription)
Estrogen or progesterone (natural)
Heart medications
High blood pressure medications
Laxatives
Recreational drug
Relaxants/sleeping pills
Testosterone
Thyroid medication
Acetaminophen (Tylenol)
Ulcer medications
Sildenafil citrate (Viagra)
Other
0
1
Antacids
Anti-anxiety medications
Antibiotics
Anticonvulsants
Antidepressant
Antifungals
Aspirin/Ibuprofen
Asthma inhalers
Beta blockers
Birth control pills
Chemotherapy
Cholesterol lowering medications
Cortisone/Steroids
Diabetic medication/insulin
Diuretics
Estrogen or progesterone (prescription)
Estrogen or progesterone (natural)
Heart medications
High blood pressure medications
Laxatives
Recreational drug
Relaxants/sleeping pills
Testosterone
Thyroid medication
Acetaminophen (Tylenol)
Ulcer medications
Sildenafil citrate (Viagra)
Other
Health Symptoms and Signs:
How often do you suffer from these digestive issues? (Q 52-70)
*
0. No, symptom does not occur, 1. Yes, minor or mild symptom, rarely occurs (monthly), 2. Moderate symptom, occurs occasionally (weekly), 3. Severe symptom, occurs frequently (daily)
0
1
2
3
Belching or gas within one hour after eating
Heat burn or acid reflux
Bloating within one hour after eating
Vegan diet (no dairy, meat, fish or eggs) (0=No, 1=Yes)
Bad breath
Loss of taste of meat
Sweat has a strong odor
Stomach upset by taking vitamins
Sense of excess fullness after meals
Feel like skipping breakfast
Feel better if you do not eat