Date of Birth
Blood Group (if known)
Vaccinations received with dates & ages (if known)
What would you like to achieve from the session?
Any known diseases/illness that run in your family?
YOUR HEALTH HISTORY
How was your birth If known?
Were you breastfeed? If yes for how long for?
Please list your physical health including any illness experienced and mental health/ challenges at these times.
Birth to 10 years
10 - 20 years
20 - 30 years
30 - 40 years
50 years to present
Current symptoms that you are experiencing
Any diagnosed illnesses, if so, are you being treated for these at present?
Are you taking any medication?
Please list all operations with dates if known
Have you ever experienced food poisoning/ severe stomach bugs/ travellers diarrhoea? Please give dates if known
Please list all pregnancy's including ones which did not make full term. (if applicable)
DIET (Please also complete separate food diary)
Please briefly describe your diet growing up
Do you eat regular meals/ eat in a hurry?
What do you eat & drink everyday, please list all foods consumed regularly, in particular any foods you feel you couldn't live without. (If not already included in food diary)
Any food cravings, if so any particular flavours?
Any allergies or intolerances
Are you taking any supplements?
Any herbal remedies
How often do you consume water per day & what type? Tap/filtered/spring/distilled etc
SLEEP, CONCENTRATION & MEMORY
How is your concentration & memory?
How many hours a night do you sleep?
Do you have trouble falling asleep?
Do you wake during the night, if so, how often, at what times and do you know why?
Do you wake up feeling refreshed?
Have you ever experienced any accidents/ trauma to the head, such as concussion? If so please give details:
Do you experience any headaches? If so, how often?
If yes is there a particular time of day or reason for experiencing?
HAIR, NAILS & SKIN
How is your hair & scalp, is it dry/greasy etc/ does the scalp flake or itch?
How is your skin? Please list any rashes, blemishes, eczema, psoriasis etc.Please state whether skin is dry, greasy, sensitive, etc.
How is your nail health? Do they grow quickly/ flake of easily? Any white spots/ marks?
Do you suffer stomach upsets, periods of nausea or vomiting?
Do you experience stomach pains or cramps, if so when? (after eating etc.)
Do you have acid reflux or experience bleaching? If so what influences these?
Do you experience any swelling/ bloating to the stomach (particularly after eating)?
Do you experience excess gas? If so, is it odorless or foul smelling? Does it ever smell sulfurous (like eggs)?
How often do you have a bowel movement per day?
How easily is this bowel movement passed? Is there any pain, blood, mucous?
Do you experience any diarrhoea or constipation? If so,how often?
How often on average do you urinate throughout the day & night?
Is their any discomfort, burning or a feeling of acidity?
Do you ever experience cystitis or nephritis?
Any history of kidney infection or kidney stones?
At what age did you start menstruating?
Are periods regular, & what is the length of your cycle?
Are periods heavy, light, clotted, long or short in duration?
Is PMS a problem? What symptoms do you experience?
ACHES & PAINS (MUSCLES & JOINTS)
Describe any aches or pains that you are currently experiencing in detail, including where in the body, what makes them feel better or worse?
Do you experience any swelling? Is the pain permanent or intermittent?
Do the aches & pains impede activities? Please give details.
Are there any particular times when they are worse? Time of day/year, after food etc.
Is there anything that helps to ease the pain?
EAR, NOSE & THROAT
Do you experience any sinus issues? Please give details.
Do you have any history of ear infections?
Is there any deafness or ringing in the ears?
Do you experience or have any history of allergies or rhinitis?
Do you experience many colds? If so how frequently?
Do you experience any sore throats, swollen glands? If so how frequently?
Do you experience any gum problems? Bleeding/ gingivitis etc.
Have you experienced tooth infections, mouth ulcers. abscesses etc? If yes how often?
How is the health of your teeth? Please explain in detail including any fillings, & if they are mercury, as well as any root canals etc.
Do you have dentures?
Do you suffer with Halitosis (bad breath)?
Do you have any breathing issues?
Do you experience or have any history of asthma, wheezing or breathing difficulties? If so, give details:
Do you regularly produce catarrh or need to clear your throat?
Are you, or have you ever been a smoker? If so, how many per day?
Are you able to breathe freely when exercising?
How much exercise do you get and what forms?
Are you able to relax?
Do you suffer with stress, anxiety or depression? please give details.
How many hours a day do you work at a computer?
Please give any other relevant information.
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