Nutritional Questionnaire
for Adults

Nutritional Questionnaire For Adults

This questionnaire is designed to provide your nutritionist with all the information necessary to build you an individual nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.

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Step 1 of 7 – Your Details

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Name*

First Last

Address*

Street Address Address Line 2 City County Post Code

Telephone Number (work)

Telephone Number (home)*

Occupation*

Age*

What is your weight (without clothes) – Stone*

Ibs

What is your height (without shoes) – Feet*

inches

Please make a list of all the health problems you would like to clear up, and indicate how long you have had these problems.

Health Problem

Duration

e.g. – Headaches 5 years.

What medications (drugs) do you take for these? State daily dosage

Under what circumstances do these problems improve?

Under what circumstances do they get worse?

What other illnesses have you had in the past ten years?

What is your normal blood pressure? (Don't worry if you don't know)

What is your resting pulse rate per minute?*

You should be sitting down, relaxed and calm when you take your pulse. Your pulse can be found inside the bony protuberance on the thumb side of your wrist. Count the number of beats in 60 seconds)

Do you have any children? If so, state age and sex

Are there any particular illnesses that they suffer from?

How many brothers and sisters do you have? State age and sex

Sex

Age

What illness is/was your father prone to?

What illness is/was your mother prone to?

Each question in this section starts with a list of symptoms associated with nutritional deficiency. Check the conditions you often suffer from. Some symptoms are repeated.

Symptoms

Mouth Ulcers

Poor Night Vision

Acne

Frequent Colds or Infections

Dry, Flaky Skin

Dandruff

Thrush or Cystitis

Diarrhoea

Rheumatism or Arthritis

Back Ache

Tooth Decay

Hair Loss

Excessive Sweating

Muscle Cramps, or Spasms

Joint Pain or Stiffness

Lack of Energy

Symptoms

Lack of Sex Drive

Exhaustion after light Exercise

Easy Bruising

Slow Wound Healing

Varicose Veins

Loss of Muscle Tone

Infertility

Frequent Colds

Lack of Energy

Frequent Infections

Bleeding or Tender Gums

Easy Bruising

Nose Bleeds

Slow Wound Healing

Red Pimples on Skin

Tender Muscles

Symptoms

Eye Pains

Irritability

Poor Concentration

‘Prickly’ Legs

Poor Memory

Stomach Pains

Constipation

Tingling Hands

Rapid Heart Beat

Burning or Gritty Eyes

Sensitivity to bright lights

Sore Tongue

Cataracts

Dull or Oily hair

Eczema or Dermatatitis

Cracked Lips

Symptoms

Lack of Energy

Diarrhoea

Insomnia

Headaches or Migraines

Poor Memory

Anxiety or tensions

Depression

Irritability

Bleeding or Tender Gums

Acne

Muscle Tremors or Cramps

Apathy

Poor Concentration

Burning Feet or tender hands

Nausea or Vomiting

Lack of Energy

Symptoms

Lack of Energy

Constipation

Tender or sore muscles

Pale Skin

Eczema

Cracked Lips

Prematurely Greying Hair

Anxiety or tension

Poor Memory

Lack of energy

Poor Appetite

Stomach Pains

Depression

Dry Skin

Poor Hair Condition

Symptoms

Exhaustion after light exercise

Anxiety or tension

Teeth Grinding

Infrequent dream recall

Water retention

Tingling Hands

Depression or Nervousness

Irritability

Muscle tremors or cramps

Lack of energy

Flaky Skin

Poor Hair Condition

Eczema or Dermatitis

Mouth over sensitive to hot or cold

Irritability

Anxiety or tension

Symptoms

Muscle cramps or tremors

Insomnia or Nervousness

Joint Pain or Arthritis

Tooth Decay

High Blood Pressure

Muscle tremors or Spasms

Muscle Weakness

Insomnia or Nervousness

High Blood Pressure

Irregular Heart Beat

Constipation

Fits or Convulsions

Hyperactivity

Depression

Pale Skin

Symptoms

Prematurely Greying Hair

Tender or Sore Muscles

Poor Appetite or Nausea

Eczema or Dermatitis

Dry, Rough Skin

Dry Eyes

Frequesnt Infections

Poor Memory

Loss of Hair or Dandruff

Excessive thirst

Poor Wound Healing

PMS or Breast Pain

Infertility

Muscle cramps or tremors

Insomnia or Nervousness

Symptoms

Sore Tongue

Fatigue or Listessness

Loss of Appetite or Nausea

Heavy Periods or Blood Loss

Poor Sense of taste or smell

White marks on more than two Finger Nails

Frequent Infections

Stretch Marks

Acne or Greasy Hair

Low Fertility

Pale Skin

Tendency to Depression

Poor Appetite

Muscle Twitches

Symptoms

Childhood Growing Pains

Dizziness or Poor sense of balance

Fit or covulsions

Sore Knees

Family History of Cancer

Signs of Premature Aging

Cataracts

High Blood Pressure

Frequent Infections

Excessive or Cold Sweats

Dizziness or Irritability after 6 hours without food

Need Frequent Meals

Cold Hands

Need for excessive sleep or drowsiness during the day

Excessive Thirst

‘Addicted’ to sweet foods

Please tick if your answer is yes, to the following questions

Cardiovascular Profile

Is your blood pressure above 40/90?

Is your pulse after 15 minutes rest above 75?

Are you more than 14lbs (7kg) over your ideal weight?

Do you smoke more than 5 cigarettes a day?

Do you do less than two hours exercise a week?

Do you eat more than one spoon of sugar a day?

Do you usually add salt to your food?

Do you have more than 2 alcoholic drinks a day?

Is there a history of heart disease in your family?

Digestion Profile

Do you chew your food thoroughly?

Do you sometimes suffer from bad breath?

Are you prone to stomach upsets?

Do you often get a burning sensation in your stomach?

Do you find it difficult digesting fatty foods?

Do you occasionally use indigestion tablets?

Do you suffer from flatulence or bloating?

Been diagnosed with Candid/Parasite overgrowth or heavy metal toxicity?

Do you experience anal irritation?

Exercise Profile

Do you take exercise that noticeably raises your heartbeat for 20 minutes more than 3 times a week?

Does your job involve vigorous activity?

Do you regularly play a sport? (football, squash, etc)

Do you have any physically tiring hobbies? (gardening, etc)

Do you consider yourself fit?

Immune Profile

Do you get more than three colds a year?

Do you find it hard to shift an infection? (cold or otherwise)

Are you prone to thrush or cystitis?

Do you often take antibiotics more than twice a year?

Is there a history of cancer in your family?

Have you ever had any growths or lumps biopsied?

Do you have an inflammatory disease such as eczema, asthma or arthritis?

Do you suffer from hayfever?

Do you suffer from allergy problems?

Have you had a major personal loss in the last year?

Pollution Risk Profile

Do you live in a city or by a busy road?

Do you spend more than 2 hours a week in traffic?

Do you exercise (job, cycle, play sports) by busy roads?

Do you smoke more than 5 cigarettes a day?

Do you buy foods exposed to exhaust fumes?

Do you generally eat non-organic produce?

Do you drink more than 1 unit or oz of alcohol a day?

Do you spend a lot of time in front of a TV or VDU?

Do you usually drink unfiltered tap water?

Stress Profile

Is your energy less now than it used to be?

Do you feel guilty when relaxing?

Do you have a persistent need for achievement?

Are you unclear about your goals in life?

Are you especially competitive?

Do you work harder than most people?

Do you easily become angry?

Do you often do 2 or 3 tasks simultaneously?

Do you have difficulty getting to sleep?

Histamine Profile

Sleep over 8 Hours

Little Sex Drive

Much Body Hair

Infrequent Colds

Sluggish Metabolism

Slow to Wake Up

Short toes and fingers

Suspicious by Nature

Fat or “well covered”

Can tolerate pain

Sleep Less than 7 Hours

Strong Sex Drive

Little Body Hair

Family History of Allergies

Fast Metabolism

‘Morning Person’

Long toes and fingers

Tends towards Depression

Don’t put weight on

Poor tolerance for Pain

Glucose Tolerance Profile

Do you need more than 8 hours sleep a night?

Are you rarely wide awake within 20 minutes of rising?

Do you need something to get you going in the morning, like a tea, coffee or cigarette?

Do you often feel drowsy during the day?

Do you get dizzy or irritable if you don’t eat often?

Do you avoid exercise due to tiredness?

Do you sweat a lot or get excessively thirsty?

Do you sometimes lose concentration?

Is your energy less now than it used to be?

Allergy Profile

Nasal Problems

Hayfever

Eczema

Dermatitis

Asthma

Migraines

Irritable Bowel Syndrome

Frequent Bloatedness

Facial Puffiness

Have you had COVID?

Yes

Unsure

If Yes, when and have you been vaccinated?

Allergy List

Do you have any allergies?

If so, what?

State type of reaction?

Have they been tested?

Are you pregnant? If so how many weeks?

Are you trying to become pregnant?

Have you ever had a miscarriage?

Do you have an IUD fitted? Or use the birth control pill?

State which:

Are your periods regular?

Are you post-menopausal?

Do you suffer from any pre-menstrual:

Bloatedness

Tiredness

Irritability

Depression

Breast Tenderness

Headaches

Please tick the questions to which you would answer "yes"

Were you breastfed?

Was a significant percentage of your diet as a child high in fatty foods and sugar?

Do you go out of your way to avoid foods containing preservatives or additives?

Do you avoid foods which contain sugar?

Do you use salt in your cooking?

Do you add salt to your food?

Do you wash fruit and vegetables before eating?

Do you normally eat white rice or flour?

Do you use a water filter or drink bottled water instead of tap water?

Do you frequently eat under stressful conditions or on the move?

Does your job involve eating out a lot?

How would you describe your appetite?

First Choice

Second Choice

Third Choice

How many teaspoons of sugar do you add to food/drinks each day?

How many coffees do you drink each day?

How many times a week do you have meals containing fried food?

How many packets of 'instant' or fast foods do you eat each week/

How many times a week do you eat chocolate or confectionery?

What percentage of your client is raw fruit and raw vegetables?

Do you wash fruit and vegetables before eating?

Do you normally eat white rice or flour?

How many cans of food do you eat per week?

How many slices of bread or rolls do you eat each week?

How many pints of milk do you drink in a week?

How many times a week do you eat red meat? (beef, pork, lamb or game)

How many times a week do you eat white meat? (poultry, fish)

What is your usual alcoholic drink? _____ _

How many glasses do you drink a week?

How many times a week do you eat live yoghurt?

Write down all the foods and drinks consumed over the next three days, starting today.

Please add as much Information as possible Including quantities eaten, brand names, and whether the food is fresh or packaged, refined or natural.

Day One

Breakfast

Lunch

Dinner

Snacks/Drinks

Day Two

Breakfast

Lunch

Dinner

Snacks/Drinks

Day Three

Breakfast

Lunch

Dinner

Snacks/Drinks

Please give two days and an additional 3 days representative of your usual eating/drinking habits?

If not, what is a more usual day?

Do you take any Nutritional Supplements on a regular basis?

Y/N please give details and brands

Nutritional Questionnaire
for Adults