Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
Telephone number
Date of birth
MM
DD
YYYY
Age
Gender
Select
Male
Female
Transgender Male
Transgender Female
Gender non-binary
Other
What is your main reason for seeking nutritional advice, wanting to go on a retreat or embarking on a wellness programme?
What outcome are you hoping to achieve?
Please list any health problems you would like to focus on?
*** Please list the health problem, what you are currently doing to manage this health problem, the onset of the problem and how long you have suffered with it ***
Have you had any major surgery, biopsies, diagnosed medical conditions, significant periods of ill health or do you suffer from any niggling or persistent health problems?
Please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc
Medications and remedies
*** Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies. List the medication or remedy, what condition it is being used for, the exact dose and the frequency of use ***
Please state when and why you last took antibiotics plus any previous times you can remember
Head
Hair
Mouth and Throat
Eyes
Ears
Chest
Gut
Do you regualrly experience any of the following digestive symptoms?
How many bowel movements do you usually have in 24 hours?
Select
1
2
3
4
5
More
Have you ever had a stomach upset after foreign travel?
Select
Yes
No
Have you noticed any recent change in bowel habit?
Are your stools pale, mild brown, dark brown, black or grey?
Do any foods cause digestive problems? If yes, which ones
Muscles
Mind, Mood and Stress
Occupation
Are you recently separated, divorced or have a new partner?
Select
Yes
No
Do you enjoy your daily life?
Select
Yes
No
Sometimes
Do you feel supported by those around you?
Select
Yes
No
Sometimes
Do you work long or irregular hours?
Select
Yes
No
Sometimes
Have you moved house or changed jobs recently?
Select
Yes
No
Are you recently bereaved?
Select
Yes
No
Is your workload bigger than you can manage?
Select
Yes
No
Sometimes
Do you feel guilty when you are relaxing?
Select
Yes
No
Sometimes
Do you have a strong drive for achievement?
Select
Yes
No
Do you sleep well?
Select
Yes
No
Sometimes
Do you often do 2 or 3 tasks simultaneously?
Select
Yes
No
What do you do for relaxation?
What other significant sources of stress do you have?
Genitals
Joints
Skin
Nails
Hands
Legs and Feet
Important Symptoms
All unusual symptoms should be reported to your doctor, however the following symptoms may mean you need immediate medical care and should be reported to your doctor as soon as possible
What is your normal blood pressure?
What is your resting pulse rate?
What is your current weight?
What is your height?
What is your waist circumference?
What is your hip circumference?
What is your blood type?
Is your weight stable, increasing or decreasing?
Did you have the normal immunisations as a child?
Grandparents
Parents
Siblings
Do you take regular exercise?
Select
Yes
No
Sometimes
What type of exercise do you do?
Do you have any active hobbies?
Do you do any of the following?
Do you drink alcohol? If so, how many units?
What is your normal alcoholic drink?
Do you smoke? If so, how many a day?
Do you think you may be addicted to anything?
Roughly what percentage of your food is organic?
Are your teeth filled with mercury amalgams?
Select
Yes
No
What time or times of day is you energy lowest?
Are any of the following true?
What are your favourite foods?
Which foods do you dislike?
Which foods do you crave?
Which foods do you find hard to give up?
Do you cater for a special diet in the household?
Who does the cooking in your household?
Do you avoid any food for cultural/ethical reasons?
Do you suspect any foods do not agree with you?
Are you allergic to any foods?
Have your recently changed your diet?
Select
Yes
No
Do you eat on the move/when stressed?
Select
Yes
No
Sometimes
Do you ever have eating binges?
Select
Yes
No
What do you binge on?
Do you chew your food thoroughly?
Select
Yes
No
Sometimes
Are you excessively thirsty?
Select
Yes
No
Sometimes
Are you pregnant?
Select
Yes
No
Maybe
If yes or maybe, how many weeks pregnant are you?
Are you trying to become pregnant?
Select
Yes
No
Are you breast feeding at present?
Select
Yes
No
Have you had problems with fertility?
Select
Yes
No
How many children have you had?
Have you ever had a miscarriage?
Select
Yes
No
Are you still menstruating?
Select
Yes
No
Are your periods regular?
Select
Yes
No
Any bleeding or spotting in between your peroids?
Select
Yes
No
Sometimes
Are your periods particularly heavy or painful?
Select
Yes
No
Sometimes
Do you have known genito-urinary conditions?
Are you happy with your sex drive?
Select
Yes
No
Sometimes
Do you suffer from any of the following?
Menstruating Women
Do you experience any of the following?
Menopausal Women
Do you experience any of the following?
Do you experience any of the following symptoms?
Do you have any known genito-urinary problems?
Do you have any known or suspected prostate problems?
Have you seen a Nutritional Therapist before?
Select
Yes
No
Have you been to a retreat, theraputic spa, medi-spa or been on a profressionally guided wellness programme before?
Select
Yes
No
If yes to either, please give details of your programme and briefly tell us what you found positve and negative about the experience
How did you find out about Bodhimaya?
What is your GP surgery phone number?
What is the address of your GP surgery?
Are any other therapists, doctors or clinics involved in your care? Please list them and what you are seeing them for
Please confirm the following by clicking the boxes below
*
All statements must be agreed to use any of Bodhimaya's services
