The

OPT IM UM HEALTH CL INIC

Questionnaire for Patients with CFS/ME, MCS, Candida, Lyme’s and Fibromyalgia

This is the Microsoft Word Version of the questionnaire.

OHC_Questionnaire_WORD_VERSION_01.doc

This version can be completed on your Mac/PC using any version of Microsoft Word. You can save
the document as you go and complete it over multiple sessions, if required.

NOTE: The word document does not import well to other word processing applications such as
iOS/Mac Pages, Google docs, etc. The document will open but check boxes are lost - making it
difficult to complete and for OHC practitioners to read.

If you don’t have Microsoft Word, please use the Acrobat PRINT version.

There are two other formats of this questionnaire:

1. Hard Copy – if you don’t own a printer, we can post a copy out to you.

2. Acrobat PDF document

OHC_Questionnaire_PRINT_VERSION_01.pdf
Can be printed from any computer or device. Fill out with a pen and then scan/email or
post back to the clinic.

NOTE: this is not an Acrobat Form and can not be filled out electronically.

FAQ – COMPLETING ELECTRONICALLY

The questionnaire says it is ‘read only’?

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5. close the document
6. attach to an email and send to the clinic.

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While completing in MS Word, you can save the file as you fill it in and come back to it over several
sessions, if you wish to do so. Once you have finished:
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3. attach to an email and send to the clinic.
The
OPTIMUM HEALT H CLINIC
Questionnaire for Patients with CFS/ME, MCS, Candida, Lyme’s and Fibromyalgia

This questionnaire is designed to provide your practitioner with all the information necessary to
build you an individual programme specifically tailored to your needs. Please answer all of the
questions as accurately as you can.
PRIVATE AND CONFIDENTIAL - PERSONAL DETAILS
Date of birth 01/12/1992 Today’s date 12/06/2017
Please state Mr Mrs Ms Miss Other      
First name Cameron Surname Milne
Postal address/postcodeLow Chimneys Mobile phone 07837979117
Whatlington Road Home phone 01424773935
Battle Occupation Student
TN330NA

Marital status Single Email milnec04@gmail.com

Any dependents (list age / gender)     
Next of Kin/Emergency Contact Christine Milne
Relationship to you Mother Telepho 07885215427
Doctor’s name ne
      Telepho 020 8856 5678
ne
Doctor’s postal address / postcode117 Brook Lane, Blackheath, London SE3 0EN

CFS HISTORY
POST CODE
For how long have you had CFS/ME? Have had symptoms for about 6 years
From when you first started to experience symptoms, how
long did it take you to get a diagnosis with CFS?      

From whom did you receive this diagnosis
(e.g., G.P., Hospital consultant)
Have you been diagnosed with any of the following- please
state which: Multiple Chemical Sensitivity (MCS),
Fibromyalgia (FM) Lyme’s Disease or Candida?
Have never received diagnosis of CFS/ME but have
serveral but not all of the symptoms.
No

Over what period of time did it take for your symptoms to fully develop: days weeks months years

Other health problems that are not related to the above: Duration
1. Eczema Lifetime

2. Hayfever Lifetime

3. Ashma Lifetime

4.            

5.            
What are your top 3 or 5 symptoms you would most like to resolve?
1. Brain Fog
2. Postexertional Fatigue
3. Low Mood
4.      
5.      

MEDICAL DETAILS
Please provide copies of test results that may be relevant to the consultation.
If you know any of the following information, please supply (don’t worry if you don’t know)

Page 1 of 12
Heigh 183cm Weigh 70kg Blood Pressure 114/67 Blood Type      
t t

Page 2 of 12
 Ye Comments
s
Are you currently following a medically prescribed      
diet?
Are you currently undergoing medical treatment?      
Are you pregnant, or aiming to become pregnant?      
Please list below any prescribed medications – currently taking or significant past use.
e.g. antibiotics, anti-depressants, anti-inflammatories, blood pressure/blood thinning medications, inhalers, medicated creams
Medication Dose Condition being treated Frequency Duration current past
e.g. simvastatin 10mg elevated cholesterol 1 daily 4 years

Sertraline 50mg anxiety 1 daily 6months

                             

                             

                             

                             

                             

Please list below any over the counter medicines – currently taking or significant past use.
e.g. anti-fungals, anti-histamines, laxatives, antacids, painkillers, anti-inflammatories, cold and ‘flu, inhalers, medicated creams, etc
Medication Dose Condition being treated Frequency Duration current past
Moisturisers       Eczema            
                             
                             
                             
                             
                             

Please list below any supplements that you are CURRENTLY taking – (indicate past supplement
use on page 7)
e.g. vitamins, minerals, herbs, fish oils, protein powder, concentrated food extracts, joint support, etc
Supplement Dose Condition being treated Frequency Duration
Ashwaghanda Root 400mg Stress daily 8months
Multi-B Complex       Fatigue daily 1 year
                             
                             
                             
                             
If you need more space to list all medications/supplements – please provide via separate
document/email.

History of your physical health – general health and significant health-related events, treatments, surgeries,
etc
Pre-birth/preconception health, if known?
     
e.g. premature birth, mum ill during pregnancy
1=terrible -
How was your health at: Comments / relevant details
5=great
1-5 years old? 1 2 3 4 5      

6-10 years old? 1 2 3 4 5      

11-15 years old? 1 2 3 4 5      

16-20 years old? 1 2 3 4 5      

21-30 years old? 1 2 3 4 5      

31-40 years old? 1 2 3 4 5      

41-50 years old? 1 2 3 4 5      

51-60 years old? 1 2 3 4 5      

Page 3 of 12
61-70 years old? 1 2 3 4 5      

71+ years old? 1 2 3 4 5      

General Patient history

Please feel free to write as much as you feel you need here, or if you are posting the form back, to add a
separate piece of paper to include more information if necessary.

Have you ever had any surgical operations or medical procedures? Please give brief descriptions and
approximate dates?      

What was going on in your life at the time you first got ill – what were the triggers, if there were any? Moving
from secondary school to college. Glandular Fever

What were your initial symptoms? It is hard to pinpoint when I noticed initial symptoms but I believe it was a
very gradual increase in tiredness and decrease in avaliable daily energy.

How have the symptoms and illness changed or developed through the course of the illness? I don’t think they
have changed at all really.

Historical Environmental Factors – factors present in your past or running up to your illness
Please feel free to write as much as you feel you need here, or if you are posting the form back, to add a
separate piece of paper to include more information if necessary.

Please describe your family situation briefly and your experiences growing up: Family situation was quite
standard. One older brother and one younger sister, parents were together until I was around 17. My grandmother and
grandfather lived next door and my grand mother died when I was quite young and my grandfather when I was around
16. School I didin't enjoy but was not traumatic and I did fairly well.

Are there any key events which you feel are relevant to you during your childhood/teens and formative years?
(e.g., parental divorce, moving home, positive/negative sibling relationships, bullied at school) My Grandfather
passing and my parent's separation were the only major events in my teens I think.

What have been the most stressful periods of your life to date, and how do you feel they have impacted you?
Since deciding to become a professional musician. Final recitals of university and other performaces have been stressful.
The death of my Grandfather and the divorce of my parents.

Have you ever experienced any physical traumas such as an accident requiring medical attention, horse or bike
fall, or an operation etc? Fractured wrist

Page 4 of 12
Type of Fatigue and Stage of Illness Please mark ‘x’ against all the types of fatigue you feel applies to you:
Post-Exertional Fatigue: feeling weakness, discomfort, or sick after minimal amounts of activity
Wired Fatigue: feeling of over-stimulation with low energy
Brain Fog Fatigue: mental impairment with confusion, disorientation, and inability to function in daily
activities
Flu-Like Fatigue: feeling weak with flu symptoms, such as a high temperature, sore throat, sore glands
Energy Fatigue: feeling of heaviness and immobilization without energy to do anything for long periods of
time
Adaption Fatigue : as long as you stay within your known limits of exertion – you are almost symptom free.
It is only when you go outside your limits that all the symptoms can come back - fatigue, muscle pain,
brain fog etc.
How would you describe the course of your illness? Please mark ‘x’ by the box that applies to you:
Constantly getting worse
Constantly improving
Persisting (no change)
Relapsing and remitting (times of no symptoms at all, then bad times)
Fluctuating (symptoms periodically wax and wane, but never disappear completely)
Beliefs – indicate how you feel about the following statements:
I want and desire to be healthy agree disagree don't know
I believe it is possible to for me to be healthy agree disagree don't know
I have or can learn the capabilities to be healthy agree disagree don't know
It is an appropriate time in my life to be healthy agree disagree don't know
There are some lifestyle benefits to being ill agree disagree don't know
I am willing to change negative lifestyle patterns, thought processes and limiting beliefs
agree disagree don't know
Once I know how, I then hold the responsibility to be healthy .............................. agree disagree don't
know
I deserve (or I am good enough) to be healthy agree disagree don't know
A - tick any statements below which feel true for you
I have high expectations of myself and people around me
I tend to spend most of my time involved with helping other people
I have experienced high levels of anxiety from a young age – anxiety is my ”middle name”
I mainly get a sense of self-worth through my external achievements
I feel out of touch with my own needs
I have a high perceived sense of danger
I can feel like a bad person if I do not “get things right”
I tend to put other people’s needs above my own
I don’t feel I was given a sense of safety as a child

I tend to be driven to obtain status and attention

I feel like I must please others or win them over all the time
I am attracted to authority but distrustful of it at the same time
I tend to have high standards and could be called a perfectionist
I mainly get a sense of self-worth by helping others
It feels like the world is not ok, and I cannot survive on my own
I feel like I am always trying to “get it right”
I tend to have people become dependent on me
I feel I cannot trust my own inner guidance, opinions or views

I am highly motivated to achieve the goals I have set in my life

If I make a mistake I feel like everyone is going to jump down my throat
I mainly get my sense of self worth through doing the right thing

Page 5 of 12
I might appear to do daring feats and be fearless on the outside, but this is a constant attempt to
overcome chronic inner fear and anxiety

Page 6 of 12
TOXIC LOAD AND DETOXIFICATION - TICK IF ANY OF THE FOLLOWING STATEMENTS WHICH APPLY TO
YOU
caffeine keeps you awake hormone related issues sensitivity to chemicals
dark circles under the eyes exercise on main roads cigarette smoker past smoker
dark coloured urine nail infection Thrush athletes foot
recreational drug use past only offensive body odour unexplained itching/rashes
headaches offensive breath rarely wash fruit and vegetables
migraines offensive stools use garden chemicals
feel worse in damp weather offensive urine water retention
sensitive to electrical equipment poor tolerance to alcohol yellow discolouration, skin/eyes
Do you fly < 1x per year 1-6x a year 6-12x a year every week not now but past frequent flyer
Do you take painkillers rarely monthly fortnightly weekly daily previous high intake
XENOBIOTIC EXPOSURE – TOXINS: DRUGS, BACTERIA, PARASITES, CHEMICALS AND RADIATION
Have you got any amalgam (mercury/metal) fillings? If yes, how many? Any removed? no
To your knowledge, did you get all inoculations while growing up? yes
When travelling do you get the relevant vaccinations for that region? yes
Did/have you an occupation which exposes you to chemicals such as working in a lab with chemicals, farming
with pesticides, as a mechanic or engineer working with petrol or oil and other chemicals, or exposure to
chemicals in the building or furniture restoration trade? no
Have you worked or lived in a ‘sick’ building i.e. with excessive damp / mould damage? no
Have you caught any illness/bugs while abroad? yes
Have you ever been bitten by a tick and did you experience any rash afterwards? no
Have you required many x-rays in your life? 1-3 4-8 9+ Comments:      
Do you feel that you have taken significant amounts of prescribed medication over your lifetime –
antibiotics/NSAIDs etc? no
Did/do you work in a hospital, day care centre, waste disposal, around animals, or in a garden? no

NOTABLE SYMPTOMS – TICK IF EXPERIENCED IN THE PAST 6 MONTHS OR IS A SIGNIFICANT HISTORIC

SYMPTOM
blood in sputum / saliva chest pain paralysis
blood in urine difficulty swallowing persistent cough
blood in vomit excessive thirst slurred speech
change in bowel movements loss of appetite unexplained bruising
change in nature of moles numbness/tingling unexplained rash

INFLAMMATION / IMMUNE SYSTEM

acne acne in teen years only eczema bacterial or viral infections
arthritis osteo rheumatoid food allergy/intolerance rarely get colds or the flu
asthma childhood asthma only gastritis regular cold/flu – slow recovery
boils gingivitis / bleeding gums psoriasis
bronchitis hayfever puffy face / eyes lids / under eye
cancer hepatitis rhinitis
cardiovascular disease hives sinusitis
herpes simplex oral genital IBS diagnosed by GP sore throat
conjunctivitis Inflammatory Bowel Disease swollen glands
cystitis UTIs past current joint pain ulcers
dermatitis labyrnthitis urethritis

SLEEP
need less than 7 hours sleep feel sleepy during the day current / history of night shifts
need more than 8 hours sleep usually nap during the day On average, what time do you:
difficulty getting to sleep >30min insomniac go to bed? 11pm
wake up during the night snoring / coughing get to
12pm
sleep?
wake too early in the morning bad dreams / nightmares wake up? 8am
wake to go to the toilet too hot too cold get up? 8:30am
difficulty waking up in morning Other comments around sleep:     
difficulty breathing at night
sleep disruption due to pain
feel un-refreshed after sleep
disordered sleeping pattern

Page 7 of 12
HYPERVENTILATION COGNITIVE SYMPTOMS
difficulty catching your breath slowness of thought slow to react
chest pain absent minded poor hand-eye coordination
brain fog confusion / disorientation depression
heart palpitations difficulty reasoning things out poor concentration
often feel tense difficulty finding the right word unable to multitask
dizziness difficulty following things loose train of thought
blurred vision difficulty driving irritability
skin feels numb difficulty comprehending info poor memory
skin gets tingling sensation difficulty retaining/recalling info frustrated
skin gets a prickling sensation difficulty with maths / numbers

MUSCLES AND PAIN DIGESTION + ASSIMILATION ELIMINATION

aching or cramping muscles bloating anal irritation / itching
burning sensation in muscles burping after meals black or blood in stool
muscle twitches or tremors dental issues constipation
muscle tension / tightness difficulty digesting fatty foods diarrhoea
muscle weakness difficulty digesting meat Flatulence after eating
muscle atrophy (shrinkage) heartburn / reflux haemorrhoids
poor muscle stamina indigestion offensive stool smell
Restless Leg Syndrome nausea after eating pale, bulky stool
sore/stiff joints in morning pain under right rib-cage undigested particles in stool
muscle pain – if yes, where? pain under right shoulder-blade stools that float sink
      regular stomach upsets On average I have a bowel motion:
stomach cramps daily every 2 3 4+ days
use antacid medication

MALE HEALTH THYROID

altered urine flow coarse hair/skin brittle fingernails
impotence cold hands/feet bruise easily
infertility difficulty losing weight feelings of dread
infrequent shaving dry hair/skin depression
loss of hair low body temperature weight gain
low sperm count protruding eyes diminished sweating
low sperm motility swollen neck/goitre thinning hair
prostatitis poor cold tolerance
undescended testicle eyebrows thinning

ADRENALS BLOOD GLUCOSE

addicted to stimulants excessive sweating often feeling thirsty low protein diet
blurred vision high blood pressure frequent urination nausea without food
clammy skin low blood pressure crave sugar /sweets need frequent meals
clumsy low libido / sex drive snacking at night mood swings
crave salty foods headaches/migraines feel faint or shaky hypoglycaemia
dazzled by lights palpitations without regular food /low blood sugars
dizziness panic attacks high carbohydrate tired, particularly
dizzy from sitting to Poor stress tolerance diet after lunch
standing

STRESSORS
changed jobs financial stress recently bereaved shift worker
competitive job loss / sick leave recently married stressful job
easily angered legal problems recently moved house unclear about your goals
easily irritated parent/dependants recently separated unhappy at home
financial loss over-committed redundancy/retirement unhappy at work

Page 8 of 12
FEMALE HEALTH AND HORMONES
do your CFS symptoms vary around your cycle? do you, or have you had an IUD fitted?
do you have periods? any difficulty conceiving?
are your periods regular? any fertility treatments?
do/have you taken HRT? natural HRT? any complications in pregnancy? miscarriages?
do/have you taken contraceptive pill/injection? menopausal peri-menopausal

age of first period?       years old age of final period?       years old

bleeding from nipple excessive hair growth osteoporosis spotting

breast cancer fibroids ovarian cysts thrush
breast lumps hair loss painful intercourse vaginal discharge
abnormal pap smear heavy periods painful periods vaginal dryness
hormonal bloating hot flushes PID vaginitis
endometriosis mastitis PMS water retention

CIRCULATION AND STRUCTURAL

abdominal weight gain club fingers accident affecting spine persistent back ache
anaemia crease in ear lobe congenital spinal issue poor posture
angina groin pain jaw pops, clicks, locks scoliosis
arteriosclerosis high blood pressure jaw deviates to left/right spinal cyst
atherosclerosis persistent nose bleeds when opened/closed spine misalignment
blood clotting pain in legs on walking persistent neck ache tinnitus
blue lips/gums/nail bed shortness of breath What is the measurement (in mm) between your upper and
calf pain or swelling thread veins lower front teeth when you open your mouth as wide as you
chest pain varicose veins can? (The average with a healthy joint is between 48mm &
54mm)      

If you have tried any of the following interventions, please tick. Describe what happened i.e.
nothing / didn’t stick with it long enough / reacted badly (if so in what way) / it helped (if so, how).
Intervention Comments Intervention Comments
Anti-Candida Diet       Milk thistle      
Blood Type Diet       Beta Glucans      
Metabolic Typing       Melatonin      
Raw food diet       Co enzyme Q 10      
Atkins Diet       Carnitine      
Elimination diet       D ribose      
Food Combining diet       Meyers Cocktail      
Juicing fruit/veg       Co enzyme A      
Fasting / ketogenic       7 Ketozyme      
Probiotics       5HTP      
Digestive enzymes       VegEPA      
Vit B12
Lactoferrin       supplement
     
Parasite cleanse       Vit B12 injections      
Combined Vit B
Colostrum       sup.
Nothing noticeable
Echinacea       Vitamin C Nothing noticeable
Astragalus       Zinc Nothing noticeable
Siberian ginseng some increased energy Liquid minerals      
Multivitamin/mine
Adrenal glandular       ral
     
Samento or Nothing noticeable, could
Cumander
      Oral magnesium
cause stomach pain
Natural anti-fungals Magnesium
(not pharmaceutical)
      injections
     
Protein powders High dosage anti-
(e.g. helped with weight gain oxidants
     
whey/soy/hemp/etc)
Green powders (e.g. Essential oils –
chlorella, spirulina,       omega 3 or 6
     
barley)

Page 9 of 12
FOOD AND DIETARY HABITS
Are there any foods that you crave? No
Are there any foods that you dislike? No
What are your favourite foods? Breads, bacon, eggs, yoghurts
Which foods would you find hard to give up? Bread
Do you eat a special diet, now or in the
past? No
(e.g. vegetarian, gluten free, no red meat)
Do you:
prepare your own food? have a good appetite?
have someone else prepare your food? have a poor appetite?
cater for a special diet in the family? mainly purchase organic produce?
eat out frequently? have you recently changed your diet?
eat when stressed? is shopping easy for you?
have a repetitive diet? have you ever had an eating disorder?
cook for more than one?

Do you regularly:
add salt to cooking or food? eat white bread/pastries?
add sugar to food or drink? eat wholegrain bread, pasta & cereals?
drink tea or coffee? eat fried food?
drink decaffeinated tea or coffee? eat processed food?
drink herbal teas? eat on the move? at desk? skip meals?
drink carbonated fizzy drinks? diet versions eat nuts/seeds? raw salted and roasted
drink fruit juice? diluted with water? eat smoked and barbecued food?
drink tap water? eat take-away /ready meals often?
drink bottled water? microwave food to heat/reheat?
drink filtered water? try to avoid additives and preservatives?
add prepared pickles and vinegar to meals? cook in bulk to save time later?
add prepared sauces and ketchups to meals? eat fresh fruit and vegetables?
cook with vegetable oils? eat organic produce?
use margarines? eat quickly
use olive oil? Coconut oil eat beans and lentils?
use butter? Ghee? wash/peel your fruit and vegetables?
aim to eat a low-fat diet? low salt diet? Were you
chew gum? breast-fed?
eat toffees or sweets?

If you are now over 18, would you consider the diet you ate growing up to be:
very healthy healthy average unhealthy very unhealthy

Please indicate how many/much

      biscuits in a week Indicate how many portions of (80g/1 apple/1 teacup)
      cakes/pastries in a week 1 fruit a day
2 raw salads in a week 2 vegetables a day
1 or 2 cheese a week Indicate how many/much
portions
2 pints of milk a week 1 cups of coffee a day
4 eggs a week 3 cups of tea a day
      white fish in a week 1 glasses of water a day
1 oily fish in a week 2 slices of bread a day
4 poultry in a week 1/2 chocolate / sweets in a week
2 red meat* in a week portions
0 cigarettes a week
2 processed meat** in a week 1 units of alcohol a week
1 unit = ½ pint beer (3.5%)
* red meat = fresh beef, pork, lamb
** processed meat = ham, bacon, sausages, burgers
small 125ml wine (9%)
25ml shot of spirit (40%)

Page 10 of 12
3 Day Food Diary
Please write down all the foods and drinks you consume over the next 3 days, starting today. One of
these days must be a weekend day or your day off, if relevant. Use a separate sheet if you prefer. Please give as
much detail as possible including time of consumption, description of the foods, drinks, quantities eaten and brand
names.
e.g. - 12:00pm M&S edamame bean and rice salad, small kettle crisps, 500ml Tropicana orange juice,
large banana

Weekday 1 Weekday 2 Weekend / day off

Time: 9am Time: 10am Time: 10am
Black tea + milk, toast, bacon, smoked mackerel with toast and Porridge mixed with peanut butter
tomato, avocado fresh coffee and chocolate nesquik
Tea + milk
1st meal
of the day

Time: 1pm Time: 1.30pm Time: 1pm

Mushroom filled pasta with olive 2 egg omlette with garlic, onion, Tinned mackrel with tomato on
oil tomato and mushroom with salad toast with salad & olive oil
Apple and olive oil.      
2nd meal Kiwi
of the day Cheese and onion crisps
     

Time: 6pm Time: 8pm Time: 7pm

Pulled pork wrap x 2 with salad Beef burger in bun with cheese Sausages with mashed potato
and mayonnaise and salad and left over roast and fried onions, broccoli and
Live yoghurt with passionfruit sweet potato. asparagus
3rd meal Live yoghurt with additional
of the day berries and passionfruit Ricepudding with honey

Time: 9:30pm Time: 4pm Time:      

Salted Peanuts: handful some oreo thins with jersey milk      

Snacks /
Additional
meals

Page 11 of 12
 Please list the types of drinks and how Glass of raspberry and apple juice Cinnamon and liquorice tea
many. Cinnamon and liquorice tea Glass of water
Eg 1x pint water, 2x large red wine, 1x
500ml juice Glass of water
1 Glass water
Additional Sanpellegrino lemon
Drinks 2x Tea

Page 12 of 12
Treatment History – Insert an ‘x’ for yes to any therapy you have already undertaken and describe if it
helped, worsened, or made no difference to your illness
Lightening Lymphatic
Process
      Drainage
     

Psychiatry       Colonic Irrigation      

CBT       Perrin Treatment      

Psychotherapy Possibly helped Massage      

Cranial
EFT       Osteopathy
     

Hypnosis       Chiropractor      

Mickel Therapy       Homeopathy      

Spiritual
Counselling/
Energetic
      Naturopath      
treatment

Reverse Therapy       Herbalist      

Reflexology/ Nutritional
Acupuncture/Reiki
      Therapist
     

Yoga/Tai Chi       Dietician      

Other Private
Meditation Somewhat helpful Medical Doctor
     

Graded Exercise       Other      

(GET)

How many different doctors and/or health practitioners do you recall having seen during the
course of your illness? 4
If not already indicated above, what other specialisms/areas of practice did they offer?      

Private laboratory history

Please include copies of the tests below if you have them and you are starting treatment on the nutrition
side of the clinic. Please mark ‘x’ by the tests you have done.
Adrenal Stress Index Test Growth Hormone

Comprehensive Stool Analysis Test Female hormones (oestrogen, progesterone etc)

Mitochondrial function Testing (ATP Profile) Neurotoxin visual contrast test

Red cell Glutathione Thyroid including TSH, T4, T3 and anti-bodies

Red cell magnesium Leaky gut test

Mercury sensitivity Test Live blood analysis

Mercury Porphiryn test or Kelmer Test IgG Food Intolerance Testing

Hair mineral analysis Candida Saliva Test

Red cell minerals Serum vitamins

Other      
Page 13 of 12
FAMILY HISTORY
Tick if known issue Indicate which family member and any relevant comments

grandmother

grandmother

relativeother
grandfather

grandfather
maternal

Maternal

paternal

paternal
siblings
mother
father
Comments

Addictive/Obsessive      
Alzheimer’s Disease      
Asthma      
Attention Deficit      
Autism/Asperger’s      
Cancer      
Cardiovascular Disease      
Chemical sensitivities      
Chronic fatigue      
Coeliac Disease      
Crohn’s Disease      
Depression      
Diabetes      
Eating Disorder      
Eczema      
Endometriosis      
Epilepsy      
Fibroids      
Food intolerance      
Gluten intolerance      
Hay fever      
Headaches      
High blood pressure      
High cholesterol      
Infertility      
Insomnia      
Irritable Bowel Syndrome      
Learning difficulties      
Migraines      
Multiple Sclerosis      
Miscarriage      
Obesity/Overweight      
Osteoarthritis      
Osteoporosis      
Thyroid issues      
(over/under)
Parkinson’s Disease      
Polycystic ovaries      
Premature birth      
Raynaud’s Disease      
Rheumatoid Arthritis      
Schizophrenia      
Sinusitis      
Sjögren’s Disease      
Ulcerative Colitis      
Underweight      
Other      

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 Please mark with an ‘x’ if you are happy for practitioners to speak to other practitioners
within the clinic about your case. Practitioners of the clinic have regular internal meetings
to discuss patients and how to provide the very best treatment possible. As part of this,
individual cases are also discussed, and by agreeing to this, you give yourself the chance of
receiving the very best treatment from the clinic team.

No I am not happy for my information to be shared with other practitioners within the
Optimum Health Clinic.

I hereby confirm that this information is correct to the best of my knowledge and that I am
not withholding any important information. I understand that neither a nutritional therapist
nor a practitioner of NLP, EFT or hypnotherapy is able to diagnose or treat medical
conditions. Neither nutritional advice nor advice from practitioners of NLP, EFT or
hypnotherapy is intended to replace the advice of medical doctors. The treatment is not a
substitute for the medical treatment of a doctor but it can work to complement it.

Date 12/6/17 Signed Cameron Milne

: :

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