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Jump Start Body Scan

Name Gender

Address

Phone Email

Age Ethnicity

Please tick any condition that you regularly experience

Do you have any chronic health issues/conditions that you have learnt to live with?

Do you have chronic pain?

Ears

Blocked

Creased earlobe

Itchy

Overly waxy

Sore

Watery

Weeping

Hair

Brittle

Dandruff

Decreased body hair

Dry

Increased body hair

Increased facial hair

Oily

Poor condition

Prematurely grey

Thinning

Skin prone to

Acne

Allergic reactions

Boils

Cellulite

Dermatitis

Easy bruising

Eczema

Excessive sweating

Hives

Itching

Pimples

Psoriasis

Rashes

Ringworm

Rosacea

Stretch marks

Thread veins

Varicose veins

Mind

Cant switch off

Difficult make

decisions

Difficulty

concentrating

Difficulty learning new

things

Dyslexia

DyspraxiaEasily confused

Easily distracted

Easily frustrated

Fogginess

Forgetful

Hyperactive

Loss of interest in daily

life

No motivation

Panic attacks

Genitals

Cystitis

Groin pain

Herpes

Impotence

Itchy

Painful intercourse

Painful or frequent

urinationPelvic inflammatory

disease

Prostatitis

Thrush

Ulcers

Unexplained discharge

Vaginal dryness

Warts

Angelica Scamardella F

07594 159 552 scamardella51@aol.com

Galley Hill, Hemel Hempstead, HP1 3RE

White european34

Ast ma

no

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Nose

Congested

Frequent nose bleeds

Hay fever

Poor sense of smell

Post-nasal drip

Prone to snoring

Rhinitis

Runny

Sinusitis

Sneezing

Stuffy

Mouth

Bad breath

Bleeding gums

Cold sores

Difficult swallowing

Dry mouth

Excess saliva

Gingivitis

Hoarse voice

Mouth ulcers

Poor sense of taste

Sore throat

Sore tongue

Tooth decay

Muscles

Cramps

Frozen

Loss of tone

Numbness

Restless legs

Sore

Spasms

Stiff

Tender

Twitches

Wasting

Weak

Skin

Brown patches

Change in moles or

lesions

Clammy

Congested

Dry

Flaky

Oily

Pale

Prematurely lined

Puffy

Rough

Scaly

Yellow

Eyes

Bags

Blurred vision

Burning

Cataracts

Double vision

Dry

Failing eyesight

GrittyItchy

Painful

Poor night vision

Prone to infection

Protruding

Sensitive to light

Sticky

Swollen eyelids

Yellowish

Joints (fingers, knees, back,

shoulders, Ect.)

Arthritic

Difficulty bending

Inflamed

Painful

Reduced mobilityRheumatic

Slow movement

Sore

Stiff

Swollen

Unsteadiness

Nails

Brittle

Dark nails

Dry

FlakyFragile

Horizontal white line

Infected

Pale nail bed

Peeling

Ridged

Split cuticles

Splitting

Spoon shaped

Thickened

White spots on 2 ormore nails

Chest

Asthma

Bronchitis

Chest discomfort/ pain

Chest infection

Diagnosed heart

condition

Difficulty breathing

Noisy breathingPalpitations

Persistent cough

Request colds

Short of breath

Wheezing

Gut

Acid reflux

Belching

Bloated

Churning

Coeliac

Constipation

Cramping

Diarrhoea

Distended

Flatulence

Haemorrhoids

Heart burn

Hiatus hernia

Irritable bowel

syndrome

Nausea

Painful

Polyps

Sensation of fullness

Sensitivity

Sluggish

Tender

Ulcers

Hands

Chilblains

Cold

Cracked

Dry

Eczema

Feel clumsy &

uncoordinated

Numbness

Poor circulation

Puffy

Sore joints

Tingling

Mood

(please tick the boxes for

predominant- even if they

conflict)

Aggressive

Agitated

Angry

Annoyed

Anxious

Balanced

Cant be bothered

Cheerful

Depressed

Easily upset

Explosive

Fluctuating

Frightened

Happy

Hyperactive

JitteryOptimistic

Overwhelmed

Pent up

Pessimistic

Sad

Suicidal

Tearful

Tense

Tired

Worried

Head

Dizziness

Feeling of hangover

Fuzzy headed

Headaches

Migraine

Poor balance

Pounding headStiff neck

Unexpected pain

Legs & feet

Aching

Athletes foot

Burning feet

Cold feet

Fungal nails

Gout

Numb

Prickling

Restless legs

Sciatica

Swollen

Tender heels

Tingling

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Medical conditions

Medication

Food allergies

What is your activity level at work/study/spare time?

Low physical activity Moderate physical activity

Heavy physical activity Vigorous activity

How many hours of sleep do

you get per night on average?

When do you typically go to

bed?

Do you smoke? How many cigarettes a day?

Weekday 1 Weekday 2 Day off

Breakfast

Lunch

Dinner

Asthma

inhalers

x

6 12

yes 10

co ee co ee co eecoffee

ham and cheesesandwich

am an c eesesandwich

toast or saa or panpasta with someParmesan cheese

usua y wee en s wehave a bbq.rarely I will have aburger, usually is

chicken breast + saladand roast pepers

Pasta an peasSteamed peas then addolive oil, garlic andfresh tomatoes, cook

for couple of min thenadd the pasta andparmesan cheese

a e potatoes wtpan fried chicken breastwith olives, capers andspring onion +

tomatoes salad

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Snacks

Drinks

Coffees ( sugar/cup) Coffees ( sugar/cup) Coffees ( sugar/cup)

Teas ( sugar/cup) Teas ( sugar/cup) Teas ( sugar/cup)

Green teas ( sugar/cup) Green teas ( sugar/cup) Green teas ( sugar/cup)

Herbal/fruit teas

( sugar/cup)

Herbal/fruit teas

( sugar/cup)

Herbal/fruit teas

( sugar/cup)

Fizzy drinks Fizzy drinks Fizzy drinks

Squash Squash Squash

Bought juices Bought juices Bought juices

Homemade juices or

smoothies

Homemade juices or

smoothies

Homemade juices or

smoothiesAlcohol Alcohol Alcohol

Water Water Water

Other Other Other

no no wee en s w ave ahome made cheese pie( curd cheese witheggs, sugar and raisins)or a cherry pie.

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