Food Analyst

Food Analyst
Questionnaire
All details on this questionnaire will be held private and confidential.
Please answer all questions as accurately as possible to facilitate a
nutritional programme being designed to best meet your needs.
TITLE
Other
DATE
Mr
SURNAME
OCCUPATION
/
CULTURAL ORIGINS
AGE/SEX OF CHILDREN
AGE/SEX OF SIBLINGS
ANY ADULT DEPENDENTS? (If yes, please briefly elaborate)
Briefly describe how you heard about this service?
What is/are your main reasons for seeking dietary analysis?
Miss
Ms
Master
Dr
FIRST NAME
DATE OF BIRTH
CONTACT DETAILS:
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___________________________________POST CODE _________
LANDLINE _____________________________________________
MOBILE _______________________________________________
EMAIL ________________________________________________
Mrs
/
HEIGHT
WEIGHT
MARITAL STATUS
GP CONTACT DETAILS:
__________________________________________
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____________________POST CODE _____________
TELEPHONE
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ARE YOU CURRENTLY SEEING YOUR GP FOR ANY HEALTH PROBLEMS?
YES / NO
IS YOUR GP AWARE OF YOU SEEKING DIETARY SUPPORT?
YES / NO
DO YOU GIVE PERMISSION FOR YOUR GP TO BE CONTACTED?
YES / NO
HAVE YOU SOUGHT PROFESSIONAL NUTRITIONAL ADVICE IN THE
PAST?
YES / NO
ARE YOU CURRENTLY SEEING ANY OTHER COMPLEMENTARY HEALTH
CARE PRACTITIONER?
YES / NO
HAVE YOU SEEN A COMPLEMENTARY HEALTH OR ANY OTHER HEALTH
PRACTITONER (OTHER THAN GP) IN THE PAST?
YES / NO
DO YOU GIVE PERMISSION FOR YOUR CONSULTATION TO BE
OBSERVED BY A STUDENT OR OTHER PROFESSIONAL?
YES / NO
(delete as appropriate)
Briefly describe what you hope to gain from dietary analysis.
Briefly describe what you perceive as your strengths and limitations with regard to your current diet and lifestyle
DISCLAIMER A Report will be compiled on the basis that the information given is true and valid. The compiled
report however is not a replacement for any existing medical treatment. Your dietary analysis is based solely
on the information you provided relating to your food intake. It does not take account of any dietary
supplements, over-the-counter medications, use of the oral contraceptive pill, HRT or any other prescribed
medications that you might be taking, e.g. antibiotics and antihistamines all of which can influence your
nutritional requirements. However, the information provided in the text of your report will endeavour to inform
you about such interactions with food.
Your analysis will be an approximation of your nutrient intake based on respected software for UK foods ‘DietPlan6’. The software is based
on McCance and Widdowson’s ‘Composition of Foods’ (6th Edition 2002) published by the Royal Society of Chemistry and the Food Standards
Agency; and The Dietary Reference Values for Food Energy and Nutrients for the United Kingdom (2003) DOH.
Both texts describe the strengths and limitations of the information provided. For example, to attain validity it would have to be assumed
that there were no errors in the way the data was collected, analysed and interpreted. If considered appropriate, information will be
provided in the text of the report to explain possible anomalies including concepts beyond those provided by acknowledged texts.
 NS3UK 2005
PERSONAL HISTORY
Starting with your current health concerns please outline all significant health problems that you can remember (including childhood events).
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Please list all
Please list any nutritional supplements you currently
REACTIONS TO MEDICINES/SUPPLEMENTS
operations under
take:
anaesthetic with dates
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Have you ever reacted badly to an anaesthetic?
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If yes, please detail
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Have you ever reacted badly to any medications?
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If yes, please detail
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Have you taken supplements in the past? If yes, please
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detail
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Have you ever reacted badly to any supplements?
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If yes, please detail
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Antibiotics: Childhood: minimal/moderate/considerable Adult: minimal/moderate/considerable Current minimal/moderate/considerable
Please highlight why you have taken antibiotics? E.g. Ear/throat/chest/urinary/dental/acne/pelvic/following trauma or surgery? Other?
Antifungals: E.g. for thrush, Athlete’s foot
never/minimal/moderate/considerable (prescribed and/or over the counter)? Current OR Past?
Antacids: Please describe
(mainly over the counter)? (mainly prescribed)?
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Pain Killers: Please describe
(mainly over the counter)? (mainly prescribed)?
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Contraceptive Pill: Please indicate whether you have taken the contraceptive pill for contraception and/or hormonal problems? Detail below your
pattern of use of the contraceptive pill. E.g. Age 14-16 for period pains, Age 18-25 for contraception, Age 20-30 for acne __________________
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Did you/Do you tolerate the contraceptive pill well?
YES/NO
If not, please detail side-effects experienced _________________
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HRT: Similarly describe your use of HRT, and whether you tolerate/tolerated HRT well ____________________________________________
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Antidepressants: Please describe in same format as above _________________________________________________________________
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PLEASE LIST ANY OTHER MEDICATIONS TAKEN CURRENTLY OR IN THE PAST
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FAMILY HISTORY
Indicate as best you can which family members were/are prone to any of the following disorders:
Grand parents GMM (maternal) GMP (paternal) or GFM (maternal) or GFP (paternal), parents M or
F, Sibling B or S, Cousins (if known) CM (maternal) or CP (paternal), Children CHM (male) or CHF
(female). Don’t know DK. SF for yourself
____________________ Addictive/Obsessive
____________________ Alzheimer’s disease
____________________ Artery disease
____________________ Asthma
____________________ Attention deficit
____________________ Autism
____________________ Cancer
____________________ Chemical Sensitivity
____________________ Chronic fatigue
____________________ Constipation
____________________ Depression
____________________ Diabetes
____________________ Disordered Eating
____________________ Eczema
____________________ Endometriosis
____________________ Epilepsy
____________________ Fibroids
____________________ Food Intolerance
____________________ Hayfever
____________________ Headaches
____________________ High blood pressure
____________________ High cholesterol
____________________ Infections
____________________ Infertility
____________________ Insomnia
____________________ Irritable bowel
____________________ Learning difficulty
____________________ Lupus
____________________ Migraines
____________________ Multiple sclerosis
____________________ Miscarriage
____________________ Obesity
____________________ Osteoarthritis
____________________ Osteoporosis
____________________ Overactive thyroid
____________________ Overweight
____________________ Parkinson’s disease
____________________ Polycystic ovaries
____________________ Poor stress response
____________________ Prematurity
__________________ Raynaud’s disease
__________________ Rheumatoid arthritis
__________________ Schizophrenia
__________________ Sinusitis
__________________ Sjrogen’s disease
__________________ Underactive thyroid
__________________ Underweight
Are your parents alive and well?
Yes/no
Are your grandparents alive and well? Yes/no
If either of your parents or grandparents died
at a young age then please explain as best you
can their cause of death.
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PLEASE DESCRIBE HOW YOU PERCEIVE THE
HEALTH OF YOUR FAMILY
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PLEASE DESCRIBE ANY MEDICAL TESTS THAT
YOU HAVE HAD IN THE PAST AND IF THERE
WERE ANY SIGNIFICANT FINDINGS
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Digestion & Elimination
C = current
RP = recent past
P = past
_____ Abdominal pain
_____ Anal irritation
_____ Black stool
_____ Bloating
_____ Bolt food
_____ Bulky stool
_____ Constipation
_____ Diarrhoea
_____ Difficulty chewing
_____ Dry mouth
_____ Eat on the move
_____ Eat when stressed
_____ Excess saliva
_____ Food poisoning
_____ Flatulence
_____ Gall stones
_____ Haemorrhoids
_____ Heartburn
_____ Hiatus hernia
_____ Incomplete motion
_____ Indigestion
_____ Irritable bowel syndrome
_____ Mucus in stool
_____ Morning nausea
_____ Nausea
_____ Offensive stool
_____ Pain under right rib cage
_____ Pale stool
_____ Parasites
_____ Pus in stool
_____ Reflux
_____ Stools that sink
_____ Stools that float
_____ Thrush
_____ Worms
STRESSORS
C = current RP = recent P = past
_____ Bereavement
_____ Changed jobs
_____ Dazzled by lights
_____ Dizzy sitting to standing
_____ Excessive exercise
_____ Feel too hot or too cold
_____ Financial loss
_____ Job promotion
_____ Legal problems
_____ Marriage
_____ Moving home
_____ Multi task
_____ New parent
_____ Overcommitted
_____ Palpitations
_____ Panic attacks
_____ Pain
_____ Personal achievement
_____ Physical illness
_____ Physical injury
_____ Redundancy
_____ Retirement
_____ Separation
Inflammation
C = current
RP = recent
past
P = past
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Acne
Arthritis
Asthma
Boils
Bronchitis
Cancer
Conjunctivitis
Crohn’s disease
Cystitis
Dermatitis
Diverticulitis
Eczema
Food allergy
Food intolerance
Gastritis
Gingivitis
Hayfever
Heart disease
Herpes
Hepatitis
Hives
IBS
Infections
Joint pains
Labyrinthitis
Mastitis
Nephritis
Oesophagitis
Otitis media
Pancreatitis
Pelvic inflammation
Prostatitis
Psoriasis
Rhinitis
Sinusitis
Twisted testicles
SLE
Ulcers
Urethrits
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Sweat a lot
Unclear about goals
Unhappy at home
Unhappy at work
Please explain your main life
stressors
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Toxic Load CH/M = current
high/moderate
RPH/M = recent past
high/moderate
PH/M = past high/moderate
_____ Alcohol
_____ Allergies
_____ Caffeine
_____ Cannabis
_____ Copper water pipes
_____ Drink tap water
_____ Electrical exposure
_____ Exercise in polluted areas
_____ Exercise levels
_____ Exposure to moulds
_____ Food additives
_____ Food pesticides
_____ Food preservatives
_____ Home decorating
_____ Home gardening
_____ In heavy traffic
_____ Infections
_____ Inflammatory disorders
_____ Intake of oily fish
_____ Lead water pipes
_____ Live in a city area
_____ Live in a smoky environment
_____ Live near pylons
_____ Live on a farm
_____ Mercury fillings
_____ Play golf
_____ Processed foods
_____ Unwashed fruit/vegetables
_____ Smoker
_____ Work with paints/chemicals
_____ Work in ‘smoky’ environment
Detoxification C = current
RP = recent
P = past
_____ Athletes foot
_____ Bad breath
_____ Caffeine keeps you awake
_____ Cellulite
_____ Chronic headaches
_____ Coated tongue
_____ Constipation
_____ Dark under eyes
_____ Dark urine
_____ Dehydration
_____ Feeling of hangover
_____ Fluctuating mood
_____ Fluctuating weight
_____ Itching
_____ Lethargy
_____ Muscle aches
_____ Offensive breath
_____ Offensive body odour
_____ Offensive urine
_____ Premature ageing
_____ Regularly dieting
_____ Verrucae/warts
_____ Water retention
_____ Weight gain
_____ Worse in damp weather
_____ Yellow discolouration skin/eyes
ALLERGY
C = current
RP = recent
P = past
_____ Anaphylaxis
_____ Bed wetting
_____ Been tested by
doctor
_____ Bloat after
eating
_____ Carry epipen
_____ Ever hospitalised
_____ Excess mucus
_____ Face ache
_____ Growing pains
_____ Hives
_____ Itchy eyes
_____ Itchy nose
_____ Itchy skin
_____ Itchy throat
_____ Learning difficulties
______ Migraines
_____ Mouth ulcers
_____ Rashes
_____ Red ears
_____ Sneeze a lot
_____ Swollen lips
_____ Swollen throat
_____ Tired after
eating
_____ Worse after eating
List foods and/or
chemicals that you react
to:
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STRESS RESPONSE
Consider your response to
stress. Do not compare
yourself with others. Only
consider how you feel in
yourself.
(please circle)
Good
OK
Poor
What measures do you
take to manage stress?
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Weight History (please use the space below to describe your weight trends over your lifetime
i.e. from birth until now)
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Are you happy with your weight?
If not, then please explain further
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HORMONAL HISTORY – WOMEN
ONLY
Yes = Y
No = N
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Any complications in labour?
Any complications in pregnancy?
Any facilitated conception/s?
Any history of endometriosis?
Any history of fibroids?
Anyhistoryofhighthyroidfunction?
Any history of hormone cancer?
Any history of miscarriage?
Anyhistoryoflowthyroidfunction?
Anyhistoryofpolycysticovaries?
Any indication of osteoporosis?
Any premature births?
Any problems breast-feeding?
Any problems conceiving?
Are you currently pregnant?
Currentlyusethecontraceptivepill?
Currently use HRT (synthetic)?
Currently use natural hormones
Did you breast-feed?
Do you / have you an IUD fitted?
Have you experienced a stillbirth?
Normal deliveries?
Planning a pregnancy?
Regular well-woman checks?
GENERAL SYMPTOMS
C = current
RP = recent past
P = past
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Abdominal weight gain
Acne
Addicted to foods
Addicted to stimulants
All boy family
All girl family
Better after exercise
Cataracts
Carry weight hips and
thighs
Carry weight back and
shoulders
Coarse hair
Coarse skin
Cold extremities
Clammy skin
Clumsy
Crave sweet food
Cry easily
Difficulty gaining weight
Dry skin
Excessive body hair
Excessive salivation
Excessive sweating
Faint without regular food
Fast metabolism
Feel cold
Feel hot
Food cravings
EXERCISE PATTERN
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Are you very active?
Are you moderately
active?
Are you sedentary?
Do you enjoy exercise?
Do exercise regularly?
Explain the type of exercise,
frequency, duration and place of
exercise.
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If you do not take regular exercise,
please indicate the factors that
prevent you from doing so.
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Fluctuating weight
Fractures
Glaucoma
Good appetite
Good teeth
Good pain tolerance
Hair loss
Hair growth
High pain threshold
High sex drive
Kidney stones
Little body hair
Long fingers and toes
Low pain threshold
Low sex drive
Loss of hair colour
Low protein intake
Macular degeneration
Morning nausea
Need to eat regularly
Palpitations
Pale skin
Poor appetite
Prone to dental decay
Protruding ey
Receding gums
Reduced sweating
Referred itches
Sexually transmitted
infection
Short fingers and toes
Swollen neck
Tired after eating
Weight loss
ENERGY, SLEEP & MOOD
C = current RP = recent P = past
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Addictive
Apathetic
Asleep after midnight
Aggressive
Angry
Anxious
Apathetic
Best evenings
Best mornings
Competitive
Creative
Cry easily
Depression
Difficulty getting to sleep
Difficulty getting up
Difficulty waking up
Dream a lot
Dull
Easily aroused
Easily fatigued
Easily provoked
Easily satisfied
Exhaustion
Expressive nature
Fatigue
Feel sleepy during the day
Feel tired all the time
Fluctuating energy
Foggy brain
Frustration
Gregarious nature
Happy
Heavy sleeper
Hyperactive
Hypercritical
Insomnia
Intuitive
Irritability
Light sleeper
Mood swings
Obsessive
Often dissatisfied
Passive
Poor concentration
Poor memory
Remember dreams
Relax easily
Sad
Self-centred
Shift worker
Sleep before midnight
Sleep less than 7 hours
Sleep more than 8 hours
Snore
Tension
Unrefreshed after sleep
Up after 9am
Wake during night
Wake refreshed
CIRCULATION
C = current RP = recent
P = past
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Active
Anaemia
Angina
Blood clots
Blue extremities
Calf pain
Chest pain
Cold hands/feet
Enjoy exercise
Groin pain
Fatty arteries
Hardened arteries
High blood pressure
High cholesterol
High triglycerides
Low blood pressure
Lung disease
Nose bleeds
Obesity
Pain in legs on walking
Red face
Sedentary
Stroke
Thick blood
Thin blood
Thread veins
Varicose veins
HORMONAL SYMPTOMS
C = current
RP = recent past
P = past
WOMEN
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Breast lumps
Heavy periods
Hormone cancer
Hot flushes
Infertility
Irregular periods
Mastitis
Painful intercourse
Painful periods
PMS
Scant periods
Vaginal bleeding
Vaginal discharge
Vaginal dryness
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Altered urine flow
Enlarged prostate
Hormone cancer
Hypospadias
Impotence
Infertility
Minimal shaving
Low sperm count
Lowspermmotility
Painfulintercourse
Prostatitis
Swollen testicles
Undescended testes
MEN
ACCIDENTS AND
INJURIES
Please detail the nature and
severity and recovery from any
accidents and injuries during your
life, with approximate dates.
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KEY OBSERVABLE SIGNS & SYMPTOMS OF POTENTIAL NUTRIENT DEFICIENCIES
(to be taken into account alongside other factors)
C = current
RP = recent past
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Acne
Bumps on skin
Burning eyes
Cataracts
Dry eyes
Dry hair
Dry skin
Dull hair
Itchy eyes
Inflamed eyelids
Peeling nails
Poor night vision
Rigid nails
Rough skin
Thickened skin
Tired eyes
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Dermatitis
Eczema
Grooved tongue
Painful gums
Red tip of tongue
Red tongue
Raw tongue
Scaly skin
Shiny/glossy tongue
Smooth tongue
Sore mouth
Swollen mouth
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Ulcers
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Tooth decay
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Burning feet
Eczema
Hair loss
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Painful tongue
Teeth grinding
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Bleeding gums
Gingivitis
Easy bruising
Enlarged veins under tongue
Pallor
Red pimples on skin
Short of breath
Slow wound healing
Thread veins
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Acne
Cracks at corners of mouth
Dermatitis
Eczema
Flaky skin
Hair loss
Oily skin
Painful tongue
Pallor
Shiny/glossy tongue
Short of breath
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Varicose veins
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Excess wrinkles for age
Pallor
Shortness of breath
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Slow wound healing
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Water retention
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Bone Pain
Fracture risk
Frequent stool
Frequent sore throat
Leg cramps
Light sleep
Tender muscles
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Difficulty walking
Pallor
Raw tongue
Red tongue
Red tip of tongue
Shiny/glossy tongue
Short of breath
Smooth tongue
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Unsound sleep
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Ulcers
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Cracks at corners of mouth
Crusty eyes
Dermatitis
Hair loss
Loss of eyebrows
Painful tongue
Purplish tongue
Scaly skin
Shiny/glossy tongue
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Cracks at corners of mouth
Painful tongue
Pallor
Raw tongue
Red tongue
Scaling lips
Short of breath
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Smooth tongue
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Watery eyes
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Constipation
Dry eyes
Dry hair
Dry mouth
Dry skin
Dry vagina
Eczema
Excess thirst
Lifeless hair
Rough skin
Slow wound healing
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Easy bruising
Eye bleeds
Gum bleeding
Heavy menstrual bleed
Nose bleeds
Pallor
Prone to fractures
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Ulcers
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Dandruff
Loose skin
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Premature ageing
A
C
E
D
B1
B2
BIO
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B3
B5
B6
B12
F
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Shortness of breath K
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Difficulty hearing
Difficulty walking
Numbness
Premature ageing
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Sore knees
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Food cravings
Obese
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Weight gain
Mn
Cr
P = past
Brittle nails
Dandruff
Dry skin
Eczema
Hair loss
Pallor
Scaly skin
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Shiny/glossy tongue EFA
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Hair breaks easily
Poor growth
Poor muscle mass
Slow wound healing
Split nails
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Water retention
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Constipation
Hair loss
Inflamed tongue
Lustreless hair
Pallor
Poor exercise tolerance
Poor skin tone
Shiny/glossy tongue
Short of breath
Spoon shaped nails
P
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Vertical ridged nails Fe
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Acne
Bumps on skin
Dandruff
Dry skin
Hair loss
Oily hair
Poor appetite
Poor night vision
Poor smell
Poor taste
Premature grey hair
Slow growth
Slow wound healing
Short of breath
Stretch marks
Ulcers
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White flecks on nails Zn
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Excess wrinkles for age
Lax joints
Pallor
Reduced skin pigment
Shortness of breath
Skin sores
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Weakness
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Brittle nails
Eczema
Leg cramps
Muscle spasms
Poor growth
Prone to fractures
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Tooth decay
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Constipation
Dry hair
Dry skin
Leathery skin
Swollen neck
Voice deepened
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Weight gain
AO
C/M
I
Blood Group (if known)
A/B/O Neg/Pos
Include all meals, snacks and drinks for the 24 hour period of
each chosen day. Include a typical Saturday and Sunday as
well as two weekdays. Remember to include all drinks,
including water, coffee, tea, juice and alcohol.
Food Analysis
E.g. 8am 2oz (70g) Kellog’s cornflakes; ¼ pint semi-skim milk; 1 teaspoon sugar; 1 mug tea with 1 tablespoon semi-skim (no sugar)
11am 2 plain digestive biscuits and 1 mug of black coffee 1pm: 2 slices of wholegrain bread with scraping of butter and 1 large tomato
Day 1 from first to last intake - record
all food, drink and timings
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If you have changed your diet recently then
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please indicate as above a typical prior day on a
separate sheet of paper. This will not be analysed
but will be taken into account in the commentary.
Do you: C
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= current RP = recent P = past
Eat our frequently?
Cook for more than one?
Enjoy entertaining?
Enjoy preparing food?
Find shopping easy?
Live alone?
Purchase much organic food?
List your most favourite foods:
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List the foods you dislike:
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List the foods you would find hard to give up:
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Explain any special diet you are following or have
followed (including vegan/vegetarian):
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Do you eat to live or live to eat?
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Briefly describe your attitude to food
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Were you breast fed? Yes / No
Were you raised on a health diet? Yes / No
Day 2 from first to last intake – record all
food, drink and timings
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Do you: C = current RP = recent
P = past
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Add salt to cooking or food?
Add sugar to food or drink?
Avoid additives and preservatives?
Choose mainly low fat foods?
Drink more than two coffee’s daily?
Drink more than two teas daily?
Drink more than 2 units of alcohol daily?
Eat a lot of chocolate?
Eat a lot of confectionery?
Eat a lot of dairy products?
Eat a lot of fried food? (not stir fry)
Eat a lot of high fat foods?
Eat a lot of ready meals?
Eat a lot of refined food?
Eat a lot of salty food?
Eat a lot of wheat products?
Eat 3 + portions of vegetables a day?
Eat 2 + portions of fruit a day?
Eat oily fish more than twice weekly?
Eat red meat more than twice weekly?
Frequently use prepared sauces?
Mainly cook with vegetable oils?
Mainly drink tap water?
Mainly eat fresh fruit and vegetables?
Mainly use margarine?
Regularly cook with polyunsaturated oils?
Regularly drink undiluted juice?
Regularly eat beans and lentils?
Regularly eat cakes and biscuits?
Regularly eat take-away meals?
Regularly eat nuts and seeds?
Regularly eat processed meats?
Regularly microwave food?
Regularly wash fruit and vegetables?
Regularly peel fruit and vegetables?
Day 3 from first to last intake - include all
food, drink and timings
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Day 4 from first to last intake - include all
food, drink and timings
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