1. Personal Details
Date of Birth
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Profession
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Phone
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Email
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Address
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2. GP Details
GP Name
GP Phone
3. Health Goals
What is your immediate, main health goal? What would you like to achieve from this consultation?
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What are your secondary health goals?
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4. Presenting Complaints
Since when, location, duration, sensations, previous treatments
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5. Previous / Current Treatment
Are you, currently or previously, receiving any other treatment for the above condition(s)? Please provide as much detail as possible, including dates and duration
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6. Medical History
Please provide a history of childhood illness, operations, major diseases, recurrent illnesses, hospitalisations, accidents, medical treatments etc in chronological order
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7. Life Traumas, Bereavements
Please provide a history of childhood illness, operations, major diseases, recurrent illnesses, hospitalisations, accidents, medical treatments etc in chronological order
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8. Prescription Medications
Please provide a history of prescription medications past and present, in chronological order. Please indicate the name of the drug, the reason for prescription, how long you took / have been taking the medication for. Also be sure to include painkillers, anti-histamines, cold, fever and flu medications … (this is important so that the medications and their impact on nutrients, side effects etc. can be researched and understood and to ensure that no supplements which may be contra-indicated are prescribed)
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9. Vaccinations
Please provide a history of vaccinations (childhood and travel) in chronological order
10. Supplements, Any Other Remedies Taken
Please provide a history of supplements (vitamins, minerals etc) or any other remedies (eg. Herbal, homeopathic) that you take or have taken. Please indicate reasons for taking, how long you took / have been taking the supplements / remedies for
11. Natural / Other Therapies
Please indicate other therapies that you have used (e.g. alternative or natural therapies), the reasons for these and the duration
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12. Family History
Please provide a brief family history of major diseases / operations etc. Include your siblings, your parents, your paternal grandparents and your maternal grandparents
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13. Digestion
Any other relevant information regarding your GI tract or digestion?
Any other relevant information? (especially regarding any history of jaundice, hepatitis, gallbladder issues ….)
Any other relevant information regarding your nervous system?
Any other relevant information regarding your endocrine system? (especially relating to thyroid and adrenal dysfunction
Any other relevant information regarding your reproductive system? (especially your fertility history and the presence of diagnosed diseases)
Any other relevant information regarding allergies or immunity? (including known triggers, which often include but are not limited to; medications, animals, food intolerances and food allergies)
Any other relevant information regarding your respiratory system?
Any other relevant information regarding your urinary tract? (including any bladder or kidney issues)
Any other relevant information regarding your cardiovascular system?
Any other relevant information regarding your Musculo-skeletal system?
Any other relevant information regarding your skin? Specifically any sensitivity to particular products or brands of skincare or cosmetics?
24. Food intake and relationship with food
Please describe your relationship with food. For example, are you relaxed around food? Are you concerned about your weight? Do you tend to over/under-eat when stressed? Do you avoid food/meals for any reason? Do you eat sitting down at a table with other people? Do you eat on the go? Any other information
Please describe in general terms your food intake. For example, are you vegan / vegetarian? Are there any foods that you restrict or do not eat for any reason (health, religious e.g)? Do you eat organic foods? Do you eat home prepared meals in general or buy ready-prepared food? Do you eat food from take-aways – what kind and how often? How many portions (if a portion = a small handful) to you eat a day of vegetables? Of fruit? How much water do you drink daily?
Please describe your history with food. Were you breastfed as a baby? Do you know when you started to eat solid foods? What sort of food did you eat as a child? Do you have a history of yo-yo dieting, calorie restriction? Any other information
Are there any foods you would find hard to restrict or eliminate?
Any other relevant information regarding your environment? (including any sensitivity to particular products or brands of skincare or cosmetics?
26. Lifestyle
Please describe your lifestyle. For example, your work/life balance, the type of work/studies you do, the presence of stressors in your life and what they are, what you do for relaxation, hobbies and interests you have
27. Exercise
Please describe any physical exercise you take – what kind and how often
28. Alcohol / Tobacco / Recreational Drugs
If yes, how much?
If yes, how much?
29. Any other information
Any other information that you feel may be relevant to your consultation that has not been included above
Day 1
Day 1 – On waking
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Day 1 – Breakfast
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Day 1 – Snacks / Drinks
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Day 1 – Lunch
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Day 1 – Snacks / Drinks
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Day 1 – Dinner
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Day 1 – Snacks / Drinks
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Day 2
Day 2 – On waking
Day 2 – Breakfast
Day 2 – Snacks / Drinks
Day 2 – Lunch
Day 2 – Snacks / Drinks
Day 2 – Dinner
Day 2 – Snacks / Drinks
Day 3
Weekend – On waking
Weekend – Breakfast
Weekend – Snacks / Drinks
Weekend – Lunch
Weekend – Snacks / Drinks
Weekend – Dinner
Weekend – Snacks / Drinks
Are these representative of your eating habits? If not, what is a more ‘usual’ day?
31. Consent & GDPR
Full name
Date
How did you hear about me?
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If you are human, leave this field blank.
