Nutritional Therapy Consultation Form

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PERSONAL DETAILS

* Fields Required

Title* First Name* Surname* Email* Contact Number*
Address* Address City/Town* County* Postcode*

EMERGENCY CONTACT DETAILS

Emergency Contact Name* Emergency Contact Number* Emergency Contact Relationship*

Date Form Completion* Marital Status* Date of Birth* Height* Weight*
Occupation / Job Description* Occupation Status* Occupation Hours*

Number of dependents

1st Dependant.
1st Dependant. 2nd Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant. 6th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant. 6th Dependant. 7th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant. 6th Dependant. 7th Dependant. 8th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant. 6th Dependant. 7th Dependant. 8th Dependant. 9th Dependant.
1st Dependant. 2nd Dependant. 3rd Dependant. 4th Dependant. 5th Dependant. 6th Dependant. 7th Dependant. 8th Dependant. 9th Dependant. 10th Dependant.

Doctors Name* Doctors Surgery Name* Doctors Surgery Number*
Surgery Address* Address City/Town* County* Postcode*

* This question needs to be completed as it is a legal requirement:
Do you give permission for you medical Doctor to be contacted?
Required
Is your medical Doctor aware of your intention to see a dietary therapist?
Have you seen a nutritional therapist or any other health professional before?

Please type in 3 health goals you want to accomplish in order of importance.


Please bring copies of any results that you have had done previously

Are you currently following a medically prescribed diet?
Are you currently undergoing medical treatment?
Are you pregnant, or aiming to become pregnant?
Do you have a medically identified food allergy or intolerance?

MEDICATIONS & SUPPLEMENTS

Please list below any prescribed drugs (current or the past)

Medication Dosage Condition being treated Frequency Duration
CurrentPast
CurrentPast
CurrentPast
CurrentPast

Please list below any over the counter medicines (current or the past)

Medication Dosage Condition being treated Frequency Duration
CurrentPast
CurrentPast
CurrentPast
CurrentPast

Please list below any vitamins, minerals, herbs & other supplements (current or the past)

Supplement Dosage Reason for Taking Frequency Duration
CurrentPast
CurrentPast
CurrentPast
CurrentPast

Please type here if you have any additional information


ZONE 1 Thorough completion of Zone 1 enables your therapist to understand your health problems in the wider context of your family history
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Is there any history of health problems or disease in your family?
Grandfathers
Grandmothers
Father
Mother
Brothers
Sisters
Sons
Daughters

ZONE 2 Thorough completion of Zone 2 provides your therapist with a comprehensive picture of your health history facilitating a functional approach to your health
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PERSONAL HEALTH HISTORY
Starting with the most current health problems please list in the space provided, all significant health problems that you have encountered in your lifetime. Indicate, where appropriate, the duration, timing and management of the health problem.

Example:

Health Problem Duration Managment Dates
Migraines 20 years Migrileve 1976 - Current
Abdominal Pain 2 years Paracetomol 1966 - 1968
Abdominal Pain 2 years Appendicectomy 1968
Asthma 25 years Ventolin 1971 - 1998
Asthma 25 years Wheat free diat Jan 2000

Please type here if you have any additional information


ZONE 3 Zone 3 helps your therapist to identify some key symptoms that might need medical referral. This is not a definitive list.
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Please TICK the following if they apply to you.


ZONE 4 The following questions help your therapist to identify areas of functional imbalance in the body.
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Please TICK the following if they apply to you.

Sleep

Energy

Weight

Digestion

Assimilation

Elimination

Inflamnation

Toxic Load & Detoxification

ZONE 5 The following questions pertain to your allergic history and/or potential for allergy.
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Please elaborate as appropriate & select YES or NO to the following questions.

Family history of allergies
Diagnosed allergy
History of a severe allergic reaction
Carry adrenalin injections for emergency use
Hospitalised for allergies
Experienced an anaphylactic shock
Been tested for allergies
List the foods and/or chemicals you react to:

Please select YES or NO to the following questions if they apply to you.

foggy brain irritable bowel poor memory genital itch itchy eyes
post-nasal drip growing pains itchy skin watery eyes asthma
itchy throat red face or ears bed-wetting joint aches rhinitis
bloating learning difficulties skin rashes hay-fever migraines
sneezing headaches mood swings swollen lips hives
mouth ulcers swollen throat hyperactivity muscle aches tension
excess mucus palpitations tired after eating

ZONE 6 These questions are mainly for women and help your therapist target hormone and nervous system links i.e. how the body communicates.
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Please select YES or NO to the following questions if they apply to you.

are you considering infertility treatment? experience complications in labour? are you planning for a baby?
experience complications in pregnancy? are you pregnant? experience difficulty breast-feeding?
are your periods regular? experience difficulty conceiving? breast fed your babies?
experience normal deliveries? do you have periods? have you been diagnosed low/high thyroid?
do you have regular well-woman check-ups? have you experienced a miscarriage? do you, or have you had an IUD fitted?
have you experienced a stillbirth? do you, or have you taken the contraceptive pill? have you had a hysterectomy?
do you, or have you taken HRT? have you received infertility treatment? do you, or have you taken a natural HRT?
have you taken hormones for any other reason?

Please TICK the following if they apply to you.


ZONE 6a Zone 6a is mainly for men.

Please TICK the following if they apply to you.


ZONE 7a The following questions help your therapist to identify the likelihood of adrenal and blood glucose imbalance.
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Please TICK the following if they apply to you.


ZONE 7b The following questions help your therapist identify stressors in your life.

Please TICK the following if they apply to you.


ZONE 7c The following questions help your therapist identify your mood.

Please TICK the following if they apply to you.


ZONE 8 The following questions help your therapist identify circulatory and transport problems in the body.
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Please TICK the following if they apply to you.


ZONE 9 This zone is another check on disorders that you might currently have or have had in the past.
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Please TICK the following if they apply to you.


Please indicate any other diagnosed health problem you have or have had in the past?


ZONE 10 Please answer the following questions relating your level of physical activity.
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Are you: type of exercise how many days per week how long is your session comments

 

active
moderately active
sedentary / inactive

Do you enjoy exercise?
If you do not participate in regular exercise, please indicate the factors that prevent you from doing so.

ZONE 11 Zone 11 helps your therapist understand factors that might influence your choice of food.
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Please Elaborate & select YES or NO the following questions if they apply to you.

Are there any foods that you crave?
Are there any foods that you dislike?
What are your favourite foods?
Which foods would you find hard to give up?
Do You Do You
or have you experienced an eating disorder? cook for more than one?
cater for a special diet in the family? enjoy eating and preparing food?
eat lots of wheat and dairy products? enjoy entertaining?
eat out frequently? have a good appetite?
have a good appetite? mainly purchase organic produce?
not avoid additives and preservatives? have you recently changed your diet?
is your diet repetitive? is shopping easy for you?

Are you following a special diet, now or in the past? Please give details


ZONE 12 Zone 12 helps your therapist identify the frequency of intake of specific foods or agents.
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Please indicate the number of exposures as applicable.

How many biscuits in a week? How many eggs a week?
How many cakes/pastries in a week? How many glasses of water a day?
How many cups of coffee a day? How many raw salads in a week?
How many cups of tea a day? How many slices of bread a day?
How many cigarettes a week? How many tomatoes a week?
How many pints of milk a week? How much cheese a week?
How many units of alcohol a week? How many portions of (a portion = 80grams or around a fist full)
How much chocolate in a week? broccoli a week?
Quantity of red meat* in a week? cabbage a week?
Quantity of white fish in a week? carrots a week?
Quantity of oily fish in a week? fruit a day?
Quantity of Poultry in a week? red berries a week?
Quantity of processed ** meat a week? vegetables a day?

* red meat = beef, pork, lamb, venison, buffalo.
** processed foods like ham, burgers, sausages and deli meats


ZONE 13 Zone 13 gives your therapist a deeper insight into your current dietary choices.
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Please select YES or NO to the following questions if they apply to you.

Do You Do You
add salt to cooking or food? avoid additives and preservatives?
add sugar to food or drink? choose mainly low-fat food?
drink tea or coffee? dilute fruit juices?
drink decaffeinated tea or coffee? drink mainly bottled water?
frequently add prepared pickles and vinegar to meals? drink mainly filtered water?
frequently add prepared sauces and ketchups to meals? drink mainly organic beverages?
mainly cook with vegetable oils? eat mainly fresh fruit and vegetables?
mainly drink tap water? eat mainly organic produce?
mainly eat white bread? eat mainly wholegrain bread, pasta & cereals?
mainly use margarines? regularly drink herbal teas?
mainly use unrefined oils? regularly eat beans and lentils?
regularly chew gum, toffees or sweets? regularly eat seeds?
regularly eat fried food? use olive oil/butter for cooking?
regularly eat processed food? wash/peel chemically treated fruit & veg?
regularly eat ready prepared meals? regularly eat salted & roasted nuts?
regularly eat smoked & barbecued food? regularly eat take-away meals?
regularly microwave food?

Where You breast-fed? raised on a healthy diet? ate well as an adolescent?

Please give details of anything else you would like to tell us.


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FORM END
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