PRIVATE & CONFIDENTIAL HEALTH QUESTIONNAIRE for Nadiya Kondratyeva Clinical Naturopathic Nutritionist & Functional Medicine Practitioner

www.tunbridgewellsnutritionist.co.uk

PERSONAL DETAILS

FULL NAME

INSTRUCTIONS

EMAIL

HEIGHT (cm / metres / feet) WEIGHT (lbs / kg / stone)

BLOOD PRESSURE

NORMAL

PHONE

DATE OF BIRTH 1) Acrobat Reader is required to fill in this form. You can download it for free here: get.adobe.com/uk/reader/

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5) Please allow yourself at least 30 minutes to complete this questionnaire.

CHILDREN'S AGE

LOW

HIGH

DATE

CHILDREN IF SO, HOW MANY?

Living with partner/spouse

LIVING CIRCUMSTANCES:

ADDRESS (street, town, county and post code)

I agree for you to contact my GP if it becomes necessary. * All personal data is kept private with accordance to our Terms & Conditions.

I agree to the above statements.

I would like to receive special offers, monthly newsletter and health tips.

Living with family or relative (s)

Living alone

GP (name and address)

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MAIN SYMPTOM SEVERITY

NOTES

MILD SEVERE

1 2 3 4 5 6 7 8 9 10

HEALTH ISSUE THAT YOU WISH TO ADDRESS

DURATION OF THIS SYMPTOM & TRIGGERS THAT AGGRAVATE IT Please list onset, duration, possible cause, previous treatment, relieving or aggravating factors.

OTHER HEALTH CONDITIONS / SYMPTOMS YOU ARE SEEKING SUPPORT FORPlease list also all diagnosed conditions and include duration (e.g. eczema - since childhood, acid reflux - 3 months).

CURRENT MEDICATIONS AND / OR SUPPLEMENTSPlease advise of any medications and / or supplements you are currently taking. These should include all over-the-counter medication (dosage, brand and frequency).

WHAT IS YOUR APPROXIMATE MONTHLY BUDGET FOR SUPPLEMENTS?

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FAMILY HISTORY

PREVIOUS MEDICAL HISTORY..................................................................................................................................................................................

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NOTES

CANCER

ECZEMA

OBESITYCELIAC DISEASESTROKE

DEMENTIAANAEMIA

DIABETES ARTHRITIS

AUTOIMMUNE CONDITIONS HIGH BLOOD PRESSURE

HEART DISEASE THYROID ISSUES DEPRESSION

NATURAL

CHILDHOOD

CHICKEN POX WOOPING COUGH OTHER - LIST IN NOTES

MEASLES MUMPS RUBELLA

HOW LONG

PREMATURE CAESARIANYOUR BIRTH

VACCINESPlease include all vaccine history and dates if known.

WERE YOU BREASTFED

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DIGESTIVE SYSTEM (Please tick if you experience any of the following)

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Type 2

Type 1

Type 3

Type 4

Type 5

Type 6

Type 7

Separate hard lumps, (hard to pass).

Hard consistency,but lumpy.

Softer than type 2, but with cracks on the surface.

Smooth and soft.

Soft blobs with clear-cut edges.

Fluffy pieces with ragged edges, a mushy stool.

Watery, no solid pieces.Entirely liquid.

Bristol Stool Chart (BSC)Your poo is important! Please tick below the type/s which are most common to you.

How many bowel movements do you have a day?

BSC is a diagnostic medical chart used as a clinical assessment tool since 1997.

ULCERS

BLOATING

ACID REFLUX

URGENCY

BLOOD IN STOOL

OTHER - SPECIFY IN NOTES

HAEMORRHOIDS

ANAL ITCHING

PARASITES

FLOATING STOOL

CRAMPS

INDIGESTION

UNDIGESTED FOOD IN STOOL

DIVERTICULITIS

CONSTIPATION

NAUSEA

DIARRHOEA

ABDOMINAL PAIN BELCHING

IBS

IBD COLITIS STOMA

ABDOMINAL HERNIA

MUCUS IN THE STOOL

SUDDEN CHANGES IN BOWEL MOVEMENTS

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NERVOUS SYSTEM (Please tick if you experience any of the following)

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..................................................................................................................................................................................NOTES HEADACHE

ANXIETY

UNRESTED SLEEP

WEIGHT GAIN

COLD EXTREMITIES

LUNCH TIME MID AFTERNOON EVENINGON WAKING

FAIREXCELLENT GOOD POOR

HAIR LOSS

WEIGHT LOSS LOW BODY TEMPERATURE

EMOTIONAL INSTABILITY EXCESSIVE THIRST FREQUENT URINATION

MIGRAINES

SWEET CRAVINGS SALT CRAVINGS TEARFUL

BAD SHORT TERM MEMORY

BAD LONG TERM MEMORY

LOW CONCENTRATION DEPRESSION SWEATS

VISUAL DISTURBANCE DIZZINESS FAINTING

ENERGY LEVELS ( When do you feel most energetic?)

DAILY ENERGY LEVEL

What do you use to boost energy when it is low?

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ENDOCRINE SYSTEM..........................................................................................................................

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CARDIOVASCULAR SYSTEM (Please tick if you experience any of the following)

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..................................................................................................................................................................................NOTES OEDEMA

REGULAR CYCLE

CHILDREN

FREQUENT URINATION ERECTILE DISFUNCTION

SURGERY - PLEASE PROVIDE DETAILS IN NOTES

LOSS OF LIBIDO STDs ENLARGED PROSTATE

HYSTERECTOMY

PRE-MENSTRUAL SYNDROME (PMS)

HRT

SURGERY - PLEASE DETAIL

INCREASED FACIAL/BODY HAIR

UTERINE FIBROIDS

TENDER BREASTS

PRE-MENSTRUAL MENOPAUSE

PAINFUL INTERCOURSE BIRTH CONTROL PILL

STDs ABORTION/S THRUSH LOW LIBIDO

CHEST PAIN SHORTNESS OF BREATH PALPITATIONS

LIGHTHEADEDNESS COLD HANDS & FEET IRREGULAR HEARTBEAT

REPRODUCTIVE SYSTEM

FEMALE

MALE

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ALLERGIES

FREQUENT BRONCHITIS

BLOCKED SINUSITIS

TONSILS REMOVED

JOINT PAIN

FREQUENT URINATION

STONG SMELLING URINE DARK COLOURED URINE FREQUENT UTIs

PAIN/BURNING ON URINATION BLOOD IN URINE

SPASMS INJURIES - PLEASE DETAIL

JOINT SWELLING BACK PAIN CRAMPS NECK PAIN

DRY THROAT EAR INFECTIONS PERSISTENT COUGH

SHORTNESS OF BREATH TONSILLITIS

POST NASAL DRIP EXCESSIVE MUCUS

PSORIASIS

AUTOIMMUNE CONDITIONS SLOW WOUND HEALING OTHER - PLEASE DETAIL

URTICARIA FREQUENT INFECTIONS COLD SORES

INTOLERANCES ASTHMA FREQUENT COLDS

IMMUNE SYSTEM (Please tick if you experience any of the following)

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RESPIRATORY SYSTEM..........................................................................................................................

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MUSCULO-SKELETAL SYSTEMS..........................................................................................................................

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EXCRETORY SYSTEM..........................................................................................................................

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DO YOU EXERCISE REGULARLY? YES NO

ACNE

NO FILLINGS MORE THAN 2 FILLINGS

DENTAL IMPLANTS MERCURY FILLINGS

ROOT CANALS

FUNGAL INFECTION (e.g. athlete's feet)

ECZEMA DANDRUFF DERMATITIS

RASHES

SKIN (Please tick if you experience any of the following)

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NOTES

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DENTAL HEALTH..........................................................................................................................

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EXERCISE..........................................................................................................................

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SLEEP..........................................................................................................................

..........................................................................................................................HOW MANY HOURS DO YOU SLEEP?

AT WHAT TIME DO YOU USUALLY GO TO BED?

AT WHAT TIME DO YOU USUALLY WAKE UP?

GOOD DREAM RECALL

DO YOU FEEL UNRESTED WHEN YOU WAKE UP?

NIGHTMARES

(please describe below)

WORK-LIFE BALANCE

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..................................................................................................................................................................................NOTES WHAT ARE THE MAJOR CHALLENGES IN YOUR LIFE AT THE MOMENT?

WHAT DO YOU DO TO RELAX AND HOW OFTEN?

DO YOU FEEL YOU HAVE ENOUGH SUPPORT? YES NO

DO YOU SWITCH OFF EASILY? YES NO

DO YOU LIKE YOUR JOB?

HOW SATISFYING IS YOUR JOB?

YES NO

1 2 3 4 5 6 7 8 9 10

DAILY STRESS LEVELS VERY HIGH HIGH MODERATE LOW

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FOOD

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..................................................................................................................................................................................NOTES MIXED DIET

SKIP BREAKFAST

GENERALLY EAT ON THE RUN

ADD SUGAR TO DRINKS

ADD LOTS OF SALT TO FOOD

GRAZE ALL THE TIME REGULARLY MISS MEALS

I LOVE FOOD & I COOK MOSTLY FROM SCRATCH

I PREFER PRE-COOKED / TAKE AWAY MEALS

FOOD EXCLUSIONS (Please list any foods you don't eat or you don't like)

WHICH BEST DESCRIBES YOUR RELATIONSHIP WITH FOOD?

VEGETARIAN VEGAN OTHER - PLEASE DETAIL

EATING HABITS

HAVE YOU EVER PERFORMED A FOOD INTOLERANCE TEST? YES NO

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FOOD LIST

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Please list how many servings you usually have of each food per week. If you don’t eat a certain food, leave it blank.If you eat it less than once a week, mention it in the notes, along with any other foods you regularly eat that are not listed.

CARBOHYDRATES SUGARS ANIMAL PROTEIN

PLANT PROTEIN

VEGETABLES (per cup)

FRUITS

WHITE BREAD

SUGAR (brown or white)

WHOLEMEAL BREAD

SOURDOUGH BREAD

HONEY

AGAVE SYRUP

MAPLE SYRUP

ARTIFICIAL SWEETENER

BANANA

NECTARINES

PERSIMMONS

KIWI

GRAPES

PEAR

APPLE

ORANGES

AVOCADO

TROPICAL (papaya, mango)

BERRIES (RAW)(blueberries, strawberries)

BEEF Red (red chicory, onions bell peppers, beetroot)Orange (pumpking, sweet potatoes, carrots)

Green (asparagus, baby salad, spinach, zucchini)

White (cauliflower, cabbage)

Cruciferous (broccoli, bok choy, cress, kale)Bitter (rocket, chicory, radishes, watercress)

Sauerkraut

Kvass

Kefir

Kombucha

Miso

Kimchi

Single/Double cream

Cow's milk

Goat's milk

PORK

CHICKEN

TURKEY

EGGS

PROCESSED MEAT (sausages, salami, bacon)

LIVER

WHITE FISH (cod, haddock)

OILY FISH (salmon, mackerel, anchovies)

SHELLFISH(crab, prawns, mussels)

TOFU/TEMPEH

CHICKPEA

BEANS/PULSES

QUINOA

NUTS

PROTEIN POWDER

PASTA/NOODLES

OATS/CEREALS

WHITE RICE

BROWN RICE

BUCKWHEAT

COUSCOUS

POTATOES

BISCUITS

CAKES

MUFFINS

PEAS

CROISSANTS

SWEET POTATOES

OTHER (please detail)

SERVING SERVING SERVING SERVING

SERVING

SERVING

SERVING

SERVING

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

FERMENTED

DAIRY

(per tsp)

NOTES

FOOD LIST

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Please list how many servings you usually have of each food per week. If you don’t eat a certain food, leave it blank.If you eat it less than once a week, mention it in the notes, along with any other foods you regularly eat that are not listed.

Water

HYDRATION Alcohol

Other drinks

Natural yogurt

Flavoured yogurt

Pasteurised cheeses

Unpasteurised cheeses

Tap water

Filtered water

Distilled water

Bottle water

Fizzy water

Instant coffee

Decaf coffee

Decaf tea

Black tea

Herbal tea

Freshly ground coffee

Juice

Cordial

Energy drink

Soft drink

Wine

Spirits

Beer/Cider

Please list below any other foods/drinks and the frequency.

Cottage cheese

Chia seeds

Linseeds

Hemp seeds

Sesame seeds

Olive oil

Butter

Pumpkin seeds

Rapeseed oil

Coconut oil

Margarine

Other vegetable oil

SEEDS

FATS

SERVING

SERVING

SERVING

SERVING

SERVING ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

ORGANIC YES

FOOD DIARY

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Please write down all the foods and drinks you would consume over a typical 3 day period. Please complete as accurately and honestly as possible. These should include breakfast, mid-morning snack, lunch, mid-afternoon snack, dinner and fluids.

Day 2Day 1 Day 3

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Thank you for taking the time to complete this form. Your detailed information will allow us to create a plan tailored to your exact needs.

Please save a copy for yourself before emailing toinfo@tunbridgewellsnutritionist.co.uk

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Kind regardsNadiya KondratyevaClinical Naturopathic Nutritionist & Functional Medicine PractitionerDip. CNM (College of Naturopathic Medicine, London)

Website: www.tunbridgewellsnutritionist.co.uk Phone: +44 (0)7474794947