Name *
Name
E.g. family history, childhood health, any traumas, chronic stress, illnesses? Any diagnoses you have received & when? Do you think that diet plays a role in your current health condition?
E.g. your appetite; any heartburn, pain, bloating/wind, constipation/diarrhoea? How soon after eating to the problems occur and where are they located? What foods/drinks make it worse/better? Does stress or anything else make it worse? What makes it better?
Have they changed in recent months/years? During the day, when are they good or bad? Are they better on holidays? Do foods/stress make them worse?
Do you have trouble falling asleep? Do you wake at night (and if so, why)? Are you restless?
Is it stable, or do you feel moody? Do you often feel down or stressed? Are there seasonal influences (e.g. worse in the winter)?
Are there any problems? Are you taking the pill? Do you experience PMS?
Do you catch colds/flus often? How long does it take you to recover? Do you have any allergies/intolerances?
Do you have any pain, stiffness, swelling? Is it similar on both sides of the body? What triggers or worsens it?
Is it dry, greasy, itchy etc.? Any rashes, acne, or other skin problems? Where on your body? What worsens it?
How much water do you drink per day? What colour is your urine?
Is your hair dry, dull, or greasy? Do you have white spots or horizontal ridging on your nails?
Where, how often, how intense? What triggers them?
What and how often? Do/did you enjoy it?
Please describe your typical weekly diet
E.g. vegetarian, vegan, gluten-free, any food allergies or intolerances?
What do you eat, and at what time? Include enough detail to show the quality & variety of foods, and portions eaten.
If the same as on weekdays, just put "same".
What do you eat, and at what time? Include enough detail to show the quality & variety of foods, and portions eaten.
If the same as on weekdays, just put "same".
What do you eat, and at what time? Include enough detail to show the quality & variety of foods, and portions eaten.
If the same as on weekdays, just put "same".