Nutritional Therapy Questionnaire

This information will be treated as strictly confidential This questionnaire will help assess how Nutritional therapy can help you with your health problems. Please answer all the questions adding any additional information at the back.

General Information
Name Eoin OMahoney Mr Date of Consultation 28-11-10 Telephone Number 0876766231 Mobile 0876766231 Email eoinomahoney@hotmail.com Date of Birth 14/02/1985 Height 6.0 Occupation Student Marital Status Single Weight 85 kilos Number of Children their age and gender n/a now Have you experienced any digestive disorder as a result of travelling abroad? No Current blood pressure (if known) ? Cholesterol level (if known) ?

Address 11 Meadowell Granstown Village Waterford

When was the last time you felt really well? Are you currently: Planning to become a father? Planning to become pregnant? Pregnant at this time? Experiencing problems with fertility? No to all

Health Profile Please make a list of all the health problems you would like to clear up, & indicate how long you have had these problems. E.g. Headaches, 5 years. (Continue on a separate sheet if you need more space) Health Problem Duration

1 2 3 4 5
Are there any circumstances when your health problems improve?

MEDICATION

Please list all medication you are currently taking and the duration and/or regularity of consumption

Please list any medication you have taken in the past and the duration and/or regularity of consumption

MEDICAL HISTORY
Please list your illnesses/operations (excluding colds and flu) starting from your childhood and including your present problems. Your health history: illnesses and operations Age of Onset Duration Related medication

If there is a family history of the following conditions please appropriate box. Please add any other conditions if not included in the M= male Grandparents Parents Siblings Cousins F = female M F M F M F M F Heart Disease
High Blood Pressure

tick the list Offspring M F

High cholesterol Arthritis Osteoporosis Diabetes Allergies Obesity Asthma Depression Alcoholism

Do you suffer from any of the following symptoms? If so please tick in the box. (Some symptoms are repeated please tick in all cases)

Vitamin A Poor night vision Acne Frequent infections Dry flaky skin Dandruff Thrush or Cystitis Diarrhoea Vitamin B3 Lack of energy Diarrhoea Insomnia Headaches or migraines Poor memory Anxiety or tension Depression Irritability Bleeding or tender gums Acne Vitamin B12 Poor hair condition Eczema or dermatitis Mouth over sensitive to hot/cold Irritability Anxiety or tension Lack of energy Constipation Tender or sore muscles Pale skin Vitamin C Frequent colds Bleeding or tender gums Easy bruising Nose Bleeds Slow wound healing Red pimples on skin Poor circulation Calcium Muscle cramps or tremors Insomnia or nervousness Joint pain or arthritis Tooth decay/gum disease Brittle nails High blood pressure Magnesium Muscle tremors or spasms Muscle weakness Insomnia or nervousness High blood pressure Irregular heart beat Constipation Hyperactivity Depression Kidney stones

Vitamin B1 Tender muscles Eye pains Irritability Poor concentration Prickly legs Poor memory Stomach pains Constipation Tingling hands Rapid heart beat Vitamin B5 Muscle tremors or cramps Apathy Poor concentration Burning feet or tender heels Nausea or vomiting Lack of energy Exhaustion after light exercise Anxiety or tension Teeth grinding Folic acid Cracked lips Premature greying hair Anxiety or tension Poor memory Lack of energy Depression Eczema Stomach pains Vitamin D Tooth decay Excessive sweating Muscle cramps or spasm Heart disease Chromium Excessive or cold sweats Need for frequent meals Sleepy during the day Excessive thirst Addicted to sweet foods Cold hands

Vitamin B2 Burning or gritty eyes Sensitivity to bright lights Sore tongue Cataracts Dull or oily hair Eczema or dermatitis Split nails Cracked lips Vitamin B6 Infrequent dream recall Water retention Tingling hands Depression or nervousness Irritability Muscle tremors or cramps Lack of energy Flaky skin Biotin Dry skin Poor hair condition Prematurely greying hair Tender or sore muscles Poor appetite or nausea Eczema or dermatitis Vitamin E Lack of sex drive Varicose veins Infertility Loss of muscle tone Fatigue after light exercise Easy bruising Iron Pale skin Sore tongue Fatigue Loss of appetite or nausea Heavy periods or blood loss Selenium Family history of cancer Signs of premature ageing Cataracts High blood pressure Frequent infections

Manganese Muscle twitches X Muscle weakness Childhood growing pains Zinc Dizziness or poor sense of balance White spots on nails Fits or convulsions Poor appetite Joint pain Hair slow to grow Poor sense of smell Eczema or spotty skin Fertility problems Tendency to depression

System Profile

Please read the following list of symptoms and fill in the number that applies: (How significant is the symptom? How true is the statement?) KEY 0= No or do not have the symptom, the symptom does not occur 1= Yes or it is a minor or mild symptom or it rarely occurs (once a month or less) 2= It is a moderate symptom or it occasionally occurs 3= It is a major symptom or it frequently occurs (daily) DIGESTIVE TRACT PROFILE Belching or gas Heartburn or acid reflux Frequent use of antacids Bad Breath Coated tongue Frequent stomach upsets Stomach upset by taking vitamins Stomach upset by greasy foods Specific foods upset your digestion Feel like skipping breakfast Feel better if you dont eat Finger nails chip or break easily Bloating Abdominal pains or cramps Diarrhoea Alternating constipation and diarrhoea Less than one bowel movement a day Black or tarry stools Undigested food in stools Light clay coloured stools Greasy or shiny stools Blood or mucous in stool Anus itching Known history of parasites, worms or bacterial infestations LIVER PROFILE Easily intoxicated by alcohol Frequent nausea Tendency to motion sickness Bitter taste in mouth especially after meals Sensitive to tobacco smoke or perfume Strong reaction to caffeine Sweat has a strong odour Skin conditions such as eczema or psoriasis Frequent migraine IMMUNE PROFILE Runny or drippy nose X Frequent infections/colds and flus Frequent antibiotic use Frequent thrush or cystitis Difficulty shaking off infections Never get sick History of Epstein Bar, Herpes, shingles, Chronic fatigue, Hepatitis or other chronic viral conditions Inflammatory conditions such as eczema, asthma or arthritis History of hayfever or allergies Nasal congestion Frequent swollen glands ENDOCRINE (HORMONAL) SYSTEM Difficulty sleeping x Require more than 8 hours sleep a night? x Hard to get going in the morning Need a stimulant e.g. coffee to get going in the morning Frequent fatigue A need for caffeine, sugar or cigarettes to keep you going during the day Frequent drowsiness during the day Dizziness or irritability if you dont eat often Frequent sweating or excessive thirst Loss of concentration and short attention span Poor memory Reduced energy Tendency to depression or social isolation Intolerance to cold or heat Cold hands and feet Weight gain/difficulty losing weight Frequent headaches Rapid or irregular heartbeat Nervousness or anxiety Teeth-grinding Irritability

CARDIOVASCULAR PROFILE
Resting pulse rate above 75 1 stone (7kg) above ideal weight Facial flushing Broken thread veins in face Cold hands and feet Haemorrhoids Heart palpitation or missed heartbeat Chest pain Numbness or tingling in left arm

WOMEN ONLY

MEN ONLY
Prostate problems Difficult to stop or start urine stream Waking to urinate at night Feeling of incomplete bowel evacuation Decreased sexual function

Depression around period Irritability around period Tearfulness around period Chocolate craving around period Breast tenderness around period Excessive menstrual flow Blood clots in menstrual flow Variations in menstrual cycle Gains around hips, thighs and buttocks Excess facial hair Bloating or water retention around period Missed period

Lifestyle profile
Please answer the questions below as fully as possible to give us a clearer picture of your current lifestyle Stress Are you prone to getting easily impatient? yes Do you find it hard to say no to people? no Do you tend to bottle up your feelings? yes Are you often/always in a hurry? yes Would you consider yourself to be a competitive person? yes Do you find it easy to relax? yes Do you feel guilty when you relax or do nothing? Sometimes Do you feel you work harder than most people? no Do you have problems organising yourself/and or others? no Are there currently any long-term stressful situations in your life? Please give details if you are comfortable doing so no Have there been long-term stressful situations in your past? Please give details if you are comfortable doing so no

In the past 12 months: no Has anyone close to you died? no Have you been divorced or separated from a partner? no Have you changed job/career? yes Have there been any major changes in your family/home and/or work situation? yes Pollution Do you live in the city or on a busy road? no Do you spend a lot of time near heavy traffic? E.g. in the car or exercising no Has the air quality in your work place been a concern? no Do you smoke or are there smokers in your home? No How many amalgam (silver) fillings do you have? Do you smoke regularly? If so how much? Occsasionally 5 a week some weeks sometimes not at all Have you ever taken recreational drugs? If so when and how often? Yes on and off once a month for two years Do you work with or have regular contact with any chemical substances e.g. paints, solvents, dry cleaning fluid, pesticides? No Do you regularly drink tap water? yes Exercise How much exercise do you do a week? Please give details every day most mornings and evenings except for sunday Is your job stationary or active? Give details stationary full time student

Do you have any active or physically tiring hobbies? Thai boxing weights and running Do you consider yourself to be fit? Yes Sleep How many hours sleep do you get on average per night? 7 to 9 Does this feel like enough? Not really Do you have difficulty falling asleep? no Do you wake in the night on a regular basis? no Do you wake feeling refreshed? No tired Past Lifestyle Were you breastfed? yes Did you have all the childhood vaccinations? yes Did you have regular childhood diseases such as measles, chickenpox etc no What was your childhood diet like? Please give details good usual homecooked meals etc Would you consider yourself to have been a happy, active child? yes

Dietary Profile
Eating habits In your household who does the majority of the cooking? me Do you enjoy cooking? Dont mind at all Is your diet based on any religious or other rules? Just health Do you avoid any foods/food groups for medical reasons? no How would you describe your appetite? big Do you ever eat simply because you are depressed, anxious or bored? no Do you often eat under stressful conditions or on the move? no Do you eat out a lot? How often? no How often do you eat take away food? What type? No once a month varies How many units of alcohol do you drink per week on average (one unit = a 125ml glass of wine, a pint of beer or lager, a 25ml unit of spirits)? Once a month 15-20 units Foods that you particularly like Foods that you particularly dislike

Stirfry, steak, chicken,

I wouldnt be too fussy

Please fill in the numbers that applies: KEY 0=Do not consume or use 1= Consume or use 2-3 times a month 2= Consume or use weekly 3= Consume or use daily Alcohol 1 Artificial Sweeteners 0 Sugar (in tea, coffee, on cereal etc 0 Sweets or chocolate 1 Fizzy Drinks 1

Please list any supplements that you are currently taking or have taken in the past. Please give details. Protein 2 to 3 times a week, have taken creatine

1 3 1 3 1 2 1 3

Cigarettes Coffee/Tea
Fast food Tap water Processed foods Added salt Fried food White bread, pasta, rice etc Above would be all wholegrain and very little bread

It would be helpful to bring these to the consultation

Do you diet often? What diets have you tired in the past? Please give details.

Please write down all the foods and drinks consumed over a 3 day period (it is advisable to include 1 weekend day), and the approximate times that they were consumed. Day 1 Breakfast Porridge, actimel, black coffee Lunch Brown pasta, chicken, veg & stir fry sauce Dinner Fish & veg or boiled eggs ,just protein shake if cutting weight Breakfast Same as day 1 Lunch Same as day 1 may vary between steak or chicken Dinner Same as day 1 could vary to chicken salad Day 2

Drinks & Snacks Water, milk with lunch, fruit between breakfast and lunch and rock cakes between dinner and lunch usually an hour before training. ( rock cakes are egg whites porridge, bran,blueberries and Day 3 Breakfast Same as 1 or 2 Lunch Same as 1 or 2 Dinner Same as 1 or 2 Drinks & Snacks Same as 1 or 2

Drinks and Snacks Would have banana and protein shake after breakfast if i go to the gym after breakfast and before college

Please list any foods that you eat on a regular basis that do not appear in this food diary Cashew nuts or walnuts Rice cakes Pineapple Strawberries

Please write any additional information here

Patient Consent Form

Patient Name: IHS Reference No:

I, ____________________ consent to my consultation at the IHS student clinic, being used for the training of IHS students of Nutritional Therapy. I understand that my student practitioner will be supervised at all times by a qualified practitioner and that the appointment will be observed by a small group of students. I understand that my name and contact details will be kept confidential and in a secure place. Students will not have access to my contact details (unless they are also working with IHS or in direct contact with me). I also understand that it is recommended that any health concerns I have, should also be discussed with my GP. IHS undertake to ensure the above. All IHS staff have to sign a confidentiality clause in their contract of work.

Signed (Patient): Date:

Signed (IHS Representative): Date:

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