New Client Questionnaire – Female Health

Hey, I’m looking forward to working together! This form is super important for our consultation. I know it’s pretty long, but the information you provide is essential for us to help you achieve your goals.

It does need to be filled out before our first consultation, so feel free to sit down with a drink and work your way through.

Personal Details

First Name *

Preferred name

Last Name *

Email Address *

Phone number *

Date of birth

Age

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

HeightYour height in centimetres

WeightYour weight in either kg, stone or lbs

Sex

Marital Status

Number of children

Occupation

How many hours a week do you work?

Referred by / How did you find out about us? *

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Use this to attach a file to your questionnaire, like a picture of your current skin condition or a blood test result.
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GP Details

Doctor's name

Phone number

Surgery address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Do you give permission for the practitioner to contact your GP if needed?YesNo

Other Practitioners

Please detail any other types of practitioners you are currently seeing or have previously visitede.g. osteopath, chiropractor, herbalist

Medical Concerns

What are your reasons for booking a consultationDescribe, when, where and how any concerns started. How often do your symptoms occur? (all day, on and off). Explain if any pain is constant, dull aching, sharp etc… Please list any previous treatments you have tried for your concerns.

When was the last time you felt well?E.g when did you last have lots of energy, clear skin etc

What do you hope to achieve through nutritional therapy?E.g increased energy, clear skin, reduced bloating, better quality of life, reduce the risk of...

Is there anything that makes you feel worse? Or worsen your condition?E.g stress, certain foods

Is there anything that makes your condition better?E.g avoiding certain foods, skincare, medications etc

Is there anything you believe triggered these symptoms?E.g a break-up, during school exams, after moving house, a viral infection

How does your condition affect you?E.g causes low self-esteem, reduced quality of life, affects work, relationships etc

Did you ever experience changes in:Skin lesionsBowel habitsSelect all that apply.

Do you have any of the following symptoms?Sudden loss of visionFrequent urination and increased thirstUnexplained weight lossDry or persistent coughDrenching night sweatsSelect all that apply.

Lifestyle

Smoking / social drug usePlease provide details of your current and previous smoking and social drug use

ExercisePlease provide details of your exercising habits. When, how long, what type?

Hobbies and relaxationPlease provide details of any hobbies, what you enjoy or do to relax and how often

StressPlease provide details of the level/frequency of stress, how often and what causes you to feel stressed (money, family, work, health etc)

Sleep

Family History

Please enter the age of your following family members:

Does anyone in your family have allergies? If yes, what kind?

List other previous illnesses or viral infections:

Have you ever had any other accidents or surgeries?

Do you have any other allergies not listed above?medications, foods etc

Please list your CURRENT medicationsPlease state for each medication: Name, Dose, Reason for taking, Duration / Start date

Please list your PAST medicationsPlease state for each medication: Name, Dose, Reason for taking, Duration / Start date

Please list any supplements you are takingPlease state for each medication: Name (include brand name), Dose, Reason for taking, Duration / Start date

Have you regularly taken or had prolonged use of any of the following:NSAIDs (e.g Paracetmol, Aspirin, Ibuprofen?)Topical steroidsInhalersAntacids (Gaviscon, Rennies, Tums)Antibiotics

Systems Review

How many times a day do you pass a stool?

DetoxificationI am sensitive to certain chemicalsI am sensitive to perfumes/fragrancesI am sensitive to caffeineI am sensitive to alcohol (get drunk with small amounts)I have bad hangoversI am exposed to second-hand smokeI am exposed to places with signs of moldPlease select if these symptoms occur currently or have done in the last 6 months.

Please state which foods you have cravings for.

How often do you suffer with tonsillitis?

How often do you suffer with a sore throat?

How often and what triggers this?

How many times a day do you urinate?

What causes this?

HairLoss/thinning of hair on headIncreased body hairIncreased facial hairDarkening of body/facial hairThinning/loss of eyebrowsDry, brittlePlease select if these symptoms occur currently or have done in the last 6 months.

Female Reproductive / Hormones

Menstrual

Age when period started

Length of period (bleeding days)

Cycle length (e.g 28 days)

When was your last menstrual period?

Do you experience mid cycle bleeding / spotting?YesNo

Have you ever missed a period?YesNo

If you are on any contraception, please state which(e.g name of pill, IUD)

Premenstrual symptoms (PMS)

Pregnancy

Were you ever pregnant?YesNo

How many times?

Did you ever have a miscarriage?YesNo

Did you ever have gestational diabetes?YesNo

How many times?

Did you ever have pre-eclampsia?YesNo

How many times?

Menopause

Are you menopausal?YesNo

Other diagnosis

Examinations

When did you last have a cervical smear?

Were the results abnormal?YesNo

Did you ever have a Breast Biopsy?YesNo

When?

Were the results abnormal?YesNo

Did you ever have a Mammogram?YesNo

When?

Were the results abnormal?YesNo

Did you ever have a Bone density/ DXA scan?YesNo

When?

Were the results abnormal?YesNo

Diet

Have you had a consultation with a nutritionist before?YesNo

Please specify.

What percentage of your diet is organic?

How many portions of vegetables do you eat daily?

Do you eat on the run or at your desk?YesNo

Do you do the cooking?YesNo

Who does?

Do you enjoy cooking?YesNo

Do you skip meals?YesNo

Do you do the food shopping?YesNo

Who does?

Where do you typically shop for food?

How many times do you eat out week?

Do you enjoy food?YesNo

At the present time, how supportive do you think the people in your household will be to your diet/lifestyle changes?1 = not very supportive, 10 = very supportive

How much ongoing support (via email) would be helpful for you to implement your plan?1 = no frequent contact, 10 = very frequent contact

Conclusion

Thank you for taking the time to fill in this questionnaire. We will go over it together at your first consultation. It will help us discover the root of your issues.

Please do send over any information you feel may be useful in your consultation, such as previous blood tests and scan results.

Is there anything else I should know?You can use the space below to let me know of anything else you feel is important but is not covered in this questionnaire.

New Client Questionnaire – Female Health

Personal Details

Upload an attachment

GP Details

Other Practitioners

Medical Concerns

Lifestyle

Sleep

Family History

Systems Review

Female Reproductive / Hormones

Menstrual

Premenstrual symptoms (PMS)

Pregnancy

Menopause

Other diagnosis

Examinations

Diet

Conclusion

Consent of personal data processing

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