Confidential Health Questionniare

This questionnaire takes about 20 minutes to complete.
All fields marked with an asterisk (*) are required.

First name

Last name

Phone

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Birthday

Height

GP's Name

Occupation

Weight

GP's Address

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Follow Specific Diet? What Type?

Time of Day

Water Intake (Litres)

Vegetables

Salad

Starchy e.g. potatoes

Greens

Other

Fruit

Berries

Bananas

Apples

Other

Dairy Produce

Cow

Sheep

Goat

Other

Eggs

Organic

Free Range

Supermaket

Other

What Allergies do you have?

What Intolerances do you have?

Bristol Stool Chart

Type 1

Separate hard lumps,

like nuts (hard to pass)

Type 4

Like a Sausage or snake, smooth & soft

Type 2

Sausage-shaped

(but lumpy)

Type 5

Soft blobs, clear-cut edges, passed easily

Type 3

Like a Sausage with cracks on its surface

Type 6

Fluffy pieces, ragged edges, a mushy stool

Type 7

Watery, no solid pieces entirely liquid

Difficulty digesting certain foods - which ones?

Gut has never been the same since - event and date?

Chemical sensitivities (e.g. car exhaust, petrol,cigarette smoke, perfumes, wine, cleaning products?)

Additional information:

History of recurrent infection: ear infections, cold/flu, bronchitis, tonsillitis, urinary tract infections,others - what and how many?

Number of antibiotics in the last 12 months?

Constant Cough, Sputum - colour?

Exposure to pollution/chemicals/etc - what and how long for?

Energy levels (0 worse to 10 Optimal)?

Stress levels (0 worse to 10 Optimal)?

How many times wake up in night, what times and why?

How many hours do you sleep per night (not total time in bed)?

Where on diagram have injury/pain and how often?

How often (mins/hours) do you exercise per week and what type?

Cycle length (e.g. 28-30d):

How many days of bleeding:

Heavy, moderate or light flow:

Have you been on the oral contraceptive pill for more than 5 years continuously in your life?

Are you pregnant or intending on conceiving soon?

Are you breastfeeding?

History abnormal pap smear - what and when?

Post-menopausal - when was your last period?

Have you had:

Miscarriages / Terminations

Hysterectomy

Tubal ligation

Other

Have you ever been to hospital and why?

Do any other significant medical conditions or symptoms run in, or are present in, your family?

Anything else that may be relevant?

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Thank you - your Questionnaire has been Submitted

Confidential Health Questionniare

This questionnaire takes about 20 minutes to complete.
All fields marked with an asterisk (*) are required.

Bristol Stool Chart

Main Presenting Symptoms

Supplements / Medication

Add Name of Product, Dose Amount, Time of Day, Reason for Taking, Date Started

Typical Daily Diet

General Food/Drink/Substance Consumption

Please Tick all that Normally Apply

Allergies & Intolerances

Stools & Urine

Digestion

Respiratory & Immune

Mind & Mental Health

Energy & Endocrine

Sleep & Nervous

Heart & Circulation

Skin, Nails & Hair

Muscloskeletal

Eyes

Ears

Exercise

Hormonal Health (Women)

Hormonal Health (Men)

Medical History

Other Stressors

Signature & Submit

Confidential Health Questionniare

This questionnaire takes about 20 minutes to complete. All fields marked with an asterisk (*) are required.

Bristol Stool Chart

Main Presenting Symptoms

Supplements / Medication

Add Name of Product, Dose Amount, Time of Day, Reason for Taking, Date Started

Typical Daily Diet

General Food/Drink/Substance Consumption

Please Tick all that Normally Apply

Allergies & Intolerances

Stools & Urine

Digestion

Respiratory & Immune

Mind & Mental Health

Energy & Endocrine

Sleep & Nervous

Heart & Circulation

Skin, Nails & Hair

Muscloskeletal

Eyes

Ears

Exercise

Hormonal Health (Women)

Hormonal Health (Men)

Medical History

Other Stressors

Signature & Submit

This questionnaire takes about 20 minutes to complete.
All fields marked with an asterisk (*) are required.