Nutritional Health Questionnaire

Contact Information
Full Name

First NameLast Name
First Name
Last Name
Concatenated Full Name
Birth Date

YearMonthDay
Occcupation
Nationality
Height
Gender
Weight
Resting Pulse
Blood Pressure
Blood Group *If Known
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Mobile
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
Street Address Line 3
City
Post Code / ZIP Code
State
Country
Full Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Relationship Status
No. of Children?
How many years apart each birth? eg.1,3,5

General Health Profile
Current Main Health Concerns - Please list all health issues including severity, and year of onset.
Reason for consulation - ie. what would you like to achieve healthwise?
Current Other Health Activities eg. Chiropractic, Counselling, Gym, Alternative therapies, etc.
What is your current daily lifestyle/activity pattern? Ie. What does a normal day look like for you? What about weekends?
What Major illnesses have you had in your life? (Include severe viral infections, such as glandular fever, childhood illnesses, eczema, asthma etc.
Present Medications / Supplements / Herbs etc. Include Contraceptives and medications taken regularly (eg. antacids or aspirin)
What Operations have you had? eg. wisdom teeth removal, childhood tonsillectomy, etc.
How were you born? Were there any complications? Premature? etc.
How were you born? Were there any complications? Premature? etc.
Were you breastfed or bottlefed and do you know what types of first foods you were given? Did you have any allergies or reactions to any foods as a child?

Diet Analysis

Describe a typical diet with your usual variations, include as many items as possible. If you have two eating styles, eg. weekday/weekend, space has been made for both.

Rows	Week	Weekend	Exceptions
Breakfast
Lunch
Dinner
Snacks
Drinks

Typical Breakfast
Typical Lunch
Typical Dinner
Typical Snacks and Drinks
How many times a week do you eat chocolate or sweets?
How many times a week do you eat fish?
How many times a week do you eat red meat?
How many pieces of fruit do you eat in a day?
Do you often eat under stressful condition?
How regularly do you eat raw vegetables or salads?
How often do you normally eat white rice/white flour or other processed grain products?
Do you add sugar to any foods or drink?
How hard/Soft is your drinking water? ie. if it causes kalky residue on your taps always it would be hard, or if it has a very high Calcium/Magnesium Ratio eg. Ca 120mg, Mg 20 or so
How many times a month do you eat out?

Comments & Consent
Additional Comments: eg. please let me know if you are only available at certain times/ days for consultations, or any other comments you would like to make about your health etc.
I give my full consent for Rachael van der Gugten to use the information provided by me in this form for consultation purposes only. I understand that my information will not be shared with any third party and the information I have provided is fully confidential. Any action I choose to take as a result of recommendations made by Rachael van der Gugten are my responsibility. PureSanté Ltd. and Rachael van der Gugten are waived of liability.
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Contact Information

General Health Profile

System Analysis:

Sleep Pattern

Vaccinations

Hereditary Profile

Diet Analysis

Comments & Consent