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

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:
Hair:
Mouth:
Eyes:
Ears:
Nose:
Muscles:
Skin:
Skin prone to:
Joints (fingers, knees, back, shoulders, etc.)
Mood:
Mind:
Chest:
Gut:
Genitals:
Hands:
Nails:
Legs and Feet
Menstruating Women:
Menopausal Women:
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
Lifestyle:
How often do you exercise? (Q 21) *
Have you recently changed your job? (Q 22) *
Have you recently divorced or separated? (Q 23) *
How frequently do you work 45 or more hours/week. (Q 24) *
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
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  
Sleepy after meals 
Fingernails chip, peel or break easily  
Anemia unresponsive to iron 
Stomach pains or cramps 
Diarrhea, chronic 
Diarrhea, shortly after meals 
Black or tarry colored stools 
Undigested food in stool