QUESTIONNAIRE 

CLINICAL NUTRITION

Our questionnaire is very extensive so please allow yourself plenty of time to fill it out thoroughly. The more information we can gain about you, the better our service will be.  

Name *
Name
Date of Birth *
Date of Birth
Your Vital Statistics
Sex *
Please select
Please select from the drop down menu.
Please select in centimetres from the drop down menu.
Please select your weight in kilograms from the drop down menu.
If known, what is your normal blood pressure?
What is your resting heart rate?
Immunisations *
As a child did you have the normal immunisations? If no then please give details in the box below.
Your health profile
What is your main reason for seeking nutritional advice? Please give as much detail as possible.
What would you like to achieve?
Please list any other health issues you would like to focus on. Please state your management of them so far in terms of operations / paracetamol / exercise etc. Also state the onset date and duration.
Please specify if you have had any recent health test.
Please give details of any other major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or whether you suffer from any chronic or niggling health problems? (eg: high blood pressure, frequent colds, recurrent urinary infections etc.)
Do you suspect your symptoms relate to a particular time or event in your life? If yes, please give details.
Please list anything you take regularly including GP prescribed medication, self prescribed medication (eg: painkillers) nutritional supplements, herbal or homeopathic remedies. Please also state the dose, condition being treated and the frequency or duration.
Please state when and why you last took a course of antibiotics, and any previous times you can remember.
Conditions *
Have you or do you suffer from any of the following? If yes please give details below.
Conditions you regularly experience
Head *
Please specify any conditions that you regularly experience.
Hair *
Please specify any conditions that you regularly experience.
Mouth *
Please specify any conditions that you regularly experience.
Eyes *
Please specify any conditions that you regularly experience.
Ears *
Please specify any conditions that you regularly experience.
Nose *
Please specify any conditions that you regularly experience.
Muscles *
Please specify any conditions that you regularly experience.
Skin *
Please specify any conditions that you regularly experience.
Skin prone to *
Please specify any conditions that you regularly experience.
Joints *
Please specify any conditions that you regularly experience.
Mood *
Please specify any conditions that you regularly experience.
Mind *
Please specify any conditions that you regularly experience.
Chest *
Please specify any conditions that you regularly experience.
Gut *
Please specify any conditions that you regularly experience.
Genitals *
Please specify any conditions that you regularly experience.
Hands *
Please specify any conditions that you regularly experience.
Nails *
Please specify any conditions that you regularly experience.
Legs and feet *
Please specify any conditions that you regularly experience.
Important symptoms *
Please select from the following list of symptoms, these may require additional medical care.
Women only
Are you pregnant and if so which trimester are you in?
Planning pregnancy
Are you trying to become pregnant?
Breast-feeding
Are you breast-feeding at present?
How many children have you had?
Fertility
Have you ever had any problems with fertility?
Miscarriage
Have you ever had a miscarriage?
What form of contraception do you use?
Menstruating
Are you still menstruating?
Periods
Are your periods regular?
Bleeding or spotting
Do you have any bleeding or spotting in between your periods?
Heavy / painful periods
Are your periods particularly heavy or painful?
HRT
Are you or have you been on HRT?
Conditions
Do you suffer from any of the following?
Sex drive
Are you happy with your sex drive?
Menstruating women
Please indicate if you experience any of the following.
Menopausal women
Please indicate if you experience any of the following.
Men only
Symptoms
Please indicate if you experience any of the following.
Your digestion
Digestion issues *
Do you regularly experience any of the following?
How many bowel movements do you generally have in 24 hours?
Please select the colour of your stools.
Do you know of any foods which cause you digestive problems?
Your eating habbits
Which are your favourite foods?
Which are the foods you dislike?
Which are the foods that you crave?
Which are the foods you would find the hardest to give up?
Nutrition related questions *
Please select the statements which are relevant to you.
What time do you eat breakfast on a weekday / workday?
Please give us as much detail as possible including quantity. List different examples if you vary your breakfast.
What time do you eat lunch on a weekday / workday?
Please give us as much detail as possible including quantity. List different examples of your lunch.
What time do you eat dinner on a weekday / workday?
Please give us as much detail as possible including quantity. List different examples of your dinner.
Do you eat between meals? Please give details of what you eat, the time and the quantity.
How much water do you drink per day?
Select the average number of cups of tea (with caffeine) per day.
Select the average number of coffees you drink per day.
Your lifestyle
Enjoyment *
Do you enjoy your daily life?
How many depend on you for your support?
Life questions *
Please select the statements which are relevant to you.
Support *
Do you feel supported by the people around you?
Job activity *
How active is your job?
Exercise *
Do you regularly exercise?
Your energy levels *
Please select the statements that apply to you.
How do you travel to work and how long does it take?
How many hours a week do you work?
How many hours a day are you sitting? Please remember that this includes driving / eating meals / screen time / possible work / public transport.
On average how many hours per week do you spend on a computer?
Hobbies *
Do you have any hobbies?
What do you do to relax?
Sleep *
Do you have trouble sleeping?
On average how many hours of sleep do you have per night?
Interrupted sleep *
Do you have interrupted sleep?
Sleep needed *
Do you need more than 8 hours of sleep per night?
What time do you generally go to bed?
What time do you generally wake up?
Toxic exposure
Polution *
Do you live, exercise or work in a city or by a busy road?
Busy roads *
Do you spend a lot of time on busy roads?
Agricultural area *
Do you live close to an agricultural area?
Unfiltered water *
Do you drink unfiltered water?
Do you drink alcohol? If so, how many units per week? To give you a rough guide: 1 pint of beer / 175ml glass of wine = 2.3 units. 125ml glass of champagne = 1.5 units. Single spirit = 2.5 units
What is your normal alcoholic drink?
Do you smoke? if so, how many a day?
Passive smoking *
Do you live or spend time in a smoky atmosphere?
Addiction *
Do you think you may be addicted to anything?
Screen time *
Do you spend a lot of time in front of a TV, computer or screen of some kind?
Mobile phone *
Do you spend a lot of time on a mobile phone?
Sun *
Do you sunbathe a lot?
Air travel *
Are you a frequent flyer?
Chemicals *
Are you exposed to chemicals through work or hobbies?
Plastics *
Do you heat, freeze or wrap foods in plastics?
Aluminium *
Do you cook or wrap foods in aluminium foil?
Antacid *
Do you regularly take antacid (indigestion) medication?
Roughly what percentage of your food is organic?
Frying / roasting *
Do you frequently fry or roast food at high temperatures?
Browned / BBQ *
Do you regularly eat browned or barbecued food?
Oily fish / shellfish *
Do you eat oily fish or shellfish more than 3 times a week?
Sweetener *
Do you regularly consume artificial sweeteners?
Teeth *
Do you regularly floss your teeth?
Mercury amalagams *
Are your teeth filled with mercury amalgams?
Please use this space for any further or relevant information you feel we should know.
Contacting you *
We would like to use your contact details to let you know about about our products and services that we think may be of interest to you. We won't share your details with any third parties. If you would like to be kept up to date in this way please check the box.
Terms and Conditions *
By using this website you agree to comply with the Your Body Programme terms and conditions. When you click on “I have read and accept the terms and conditions of use” you agree to be bound by the terms that relate to registered users. Please click here to refer to our legal page.
Thanks for taking the time to complete our questionnaire. If you're happy with your answers please now click submit.