Health Profile Form

1. Personal Details

Name

First Name

Last Name

Gender

Male

Female

Other

Marital Status

Single

Married

Other

Date of Birth

Profession

Phone

Address

2. GP Details

GP Name

GP Phone

Do I have your permission to contact your GP should it become necessary?

Yes

3. Health Goals

What is your immediate, main health goal? What would you like to achieve from this consultation?

What are your secondary health goals?

4. Presenting Complaints

Since when, location, duration, sensations, previous treatments

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

6. Medical History

Please provide a history of childhood illness, operations, major diseases, recurrent illnesses, hospitalisations, accidents, medical treatments etc in chronological order

7. Life Traumas, Bereavements

Please provide a history of childhood illness, operations, major diseases, recurrent illnesses, hospitalisations, accidents, medical treatments etc in chronological order

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)

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

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

13. Digestion

Any other relevant information regarding your GI tract or digestion?

14. Liver and Gallbladder

Please tick any of the below that you experience regularly

Liver and Gallbladder – Emotional

Anger

Irritation

Any other relevant information? (especially regarding any history of jaundice, hepatitis, gallbladder issues ….)

15. Nervous System

Please tick any of the below that you experience regularly

Nervous System – Emotional

Anxiety

Fears

Any other relevant information regarding your nervous system?

16. Endocrine System

Please tick any of the below that you experience regularly

Endocrine System – Emotional

Irritability

Restlessness

Nervousness

Any other relevant information regarding your endocrine system? (especially relating to thyroid and adrenal dysfunction

17. Reproductive System (male and female)

Please tick any of the below that you experience regularly

Reproductive System – Emotional

Overwhelm

Financial stress

Lack of fulfilling relationship

Any other relevant information regarding your reproductive system? (especially your fertility history and the presence of diagnosed diseases)

18. Allergies and Immunity

Please tick any of the below that you experience regularly

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)

19. Respiratory System

Please tick any of the below that you experience regularly

Respiratory System – Emotional

Experiencing loss

Grief

Sadness

Any other relevant information regarding your respiratory system?

20. Urinary Tract (filtering system)

Please tick any of the below that you experience regularly

Urinary Tract – Emotional

Fear

Insecurity

Any other relevant information regarding your urinary tract? (including any bladder or kidney issues)

21. Cardiovascular System

Please tick any of the below that you experience regularly

Cardiovascular System – Emotional

Any other relevant information regarding your cardiovascular system?

22. Musculo-skeletal System

Please tick any of the below that you experience regularly

Musculo-skeletal System – Emotional

Fear

Insecurity

Any other relevant information regarding your Musculo-skeletal system?

23. Skin

Please tick any of the below that you experience regularly

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?

25. Environment

Please tick any of the below that you experience regularly.

Environment – Physical

Exposure to fumes (paint, salon, car)

Skin disorders (e.g. psoriasis, eczema)

Live near mobile masts / power lines

Live near a busy road

Mercury fillings (silver ones)

Proximity to pesticides

Use of household chemicals

Loss of hair

Work on a computer

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

Do you smoke?

Yes

If yes, how much?

Do you drink alcohol?

Yes

If yes, how much?

Do you take recreational drugs?

Yes

29. Any other information

Any other information that you feel may be relevant to your consultation that has not been included above

30. Food Diary

Write down all food/drinks that are consumed over 3 days (2 weekdays and 1 weekend for nutritional consultations). Add as much information as possible (including time eaten, whether food is fresh or packaged)

Day 1

Day 1 – On waking

Day 1 – Breakfast

Day 1 – Snacks / Drinks

Day 1 – Lunch

Day 1 – Snacks / Drinks

Day 1 – Dinner

Day 1 – Snacks / Drinks

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

Consent

I confirm that I request nutritional and/or homeopathic treatment and understand that all above information will be used confidentially and for the purposes of such consultation(s) with Veneta Daniels only

Full name

Date

As part of the General Data Protection Regulation (GDPR) written consent is required regarding how you can be contacted during treatment. I give my consent for my personal data including my health data to be held and to be contacted between appointments by:

Telephone

Post

How did you hear about me?

Captcha

If you are human, leave this field blank.

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Health Profile Form

1. Personal Details

2. GP Details

3. Health Goals

4. Presenting Complaints

5. Previous / Current Treatment

6. Medical History

7. Life Traumas, Bereavements

8. Prescription Medications

9. Vaccinations

10. Supplements, Any Other Remedies Taken

11. Natural / Other Therapies

12. Family History

13. Digestion

14. Liver and Gallbladder

15. Nervous System

16. Endocrine System

17. Reproductive System (male and female)

18. Allergies and Immunity

19. Respiratory System

20. Urinary Tract (filtering system)

21. Cardiovascular System

22. Musculo-skeletal System

23. Skin

24. Food intake and relationship with food

25. Environment

26. Lifestyle

27. Exercise

28. Alcohol / Tobacco / Recreational Drugs

29. Any other information

30. Food Diary

Day 1

Day 2

Day 3

31. Consent & GDPR

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