Health Profile Form
Section 1: Contact and basic information
1. Name*
First Name
Last Name
2. Email*
example@example.com
3. Address*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Phone Number*
Please enter a valid phone number.
Format: (000) 000-0000.
5. Gender*
Male
Female
6. Date of Birth*
-
Month
-
Day
Year
Date
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Section 2: Essential Current Health Information and History
We are piecing together a picture of your current health status and general wellbeing. Many health issues are not due to solely one cause and are most often related to stress, as well as diet and lifestyle
7. Relationship Status
Single
Married
Separated
Divorced
Widowed
Cohabiting
8. Profession/job*
9. Do you give consent for me to contact your GP/Healthcare provider if necessary, for example, to recommend a test after consultation.*
Yes
No
10. If answer is yes to question 9, please give contact details for GP; name, address, email and phone number
11. Please describe the condition(s) about which you are seeking treatment and your desired goals/outcome*
12. Please describe any treatment you are having, or have had, for the conditions described above.*
13. Please list also medications, supplements and vitamins etc that you are currently taking, including dose and frequency. Include and long-term prescriptions such as birth control pill, IUD (coil), blood pressure tablets etc. This information is vital in order to ensure that any nutritional recommendations are not contra-indicated by the medications you are taking*
14. Medical History: List all major diseases, accidents, hospital admissions and medical treatments and traumas in chronological order. Please include any childhood illnesses, dental work etc.*
15. Please list all alleriges and intolerances, such as intolerances to food, medications, hay fever, cats, gluten, dairy etc. Please also list any medications you take to alleviate these allergies, such as antihistamines, inhalers and/or steroids*
16. Please give your height and current weight
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Section 3: Diving deeper.
Many of our health issues are related to past trauma, our upbringing, and events throughout our lives. We now know through the latest developmental research in psychology and neuroscience that ACEs, or Adverse Childhood Events, play a significant role in our biochemistry and neurological development. The following questions go deeper and are more nuanced. At times these questions may seem intrusive - please answer only what you feel comfortable with.
17. Childhood: Describe what you know of your birth, for example, full-term or premature, induced, Caesarian section, birth complications, emergency conditions etc
18. Childhood: Did you feel safe growing up? If not, please explain
19. Childhood: Was alcohol or substance abuse prevalent in your childhood home? If yes, please explain
19. Have you had any violent or otherwise traumatic experiences in life, or have you witnessed and violence or abuse? Please give details as much as you feel able to
20. Family Medical History: Please list all diseases of blood -relations, including cause and age of death where applicable. Please also indicate where there may be a history of alcoholism, drug addiction, behavioural problems, birth defects, disabilities, or any other unusual condition or imbalance such as allergies, asthma etc. Include paternal grandparents, maternal grandparents, mother, father, siblings and children
21. Please list all vaccinations, any reactions and date administered. Include any travel and COVID vaccinations plus date administered where possible*
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Section 4: Describing your current health, looking at symptoms and tying them to underlying causes.
In functional medicine we are predominantly interested in discovering the underlying cause, not simply treating symptoms. In completing this section we are getting a snapshot of your current symptoms so we can conduct an investigation into where the symptoms are rooted. Completing this section in detail may well reveal
22. Intestinal Health - According to the chart below, please tick the type, or types, that most reflect your stool. Tick all that apply
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
23. Cardiovascular: Select any of the below that refer to you currently
Fatigue
Numbness of hands or feet
Noises in Head or ringing of ears (tinnutis)
Drowsy
Palpitations
Sigh frequently, air hunger
Increased need for fresh air
Swollen ankles, worse at night
Tendency to anaemia
Smoker
Shortness of breath
Swelling of legs and ankles
Light-headedness/loss of consciousness
Obesity
High C-reactive protein (CRP - a protein made by the liver - indicates inflammation)
Little or no exercise
Chest pain
Fatigue/pain in arms or legs
High Calcium Score Test (CAC)
24. Digestion: Select any of the below that refer to you currently
Lower bowel gas several hours after eating
Burning stomach sensation relieved by eating
Indigestion
Difficult bowel movements
Bloating
Difficult bowel movements
Ulcers/colitis/gastritis/IBS
Bad breath
Coated tongue
Rectal itching
Inability to gain weight
Excessive belching/burping
Stools float
Strain to pass a stool
Bloated after a meal
Blood in stool
Stool a strange colour
Stool a strange smell
Diarrhoea
Constipation
Alternating diarrhea/constipation
25. This section only if you have submitted a gut test, such as GI MAP test or GI Ecologix. Bowel Habits: Please state bowel movements per day, colour of stool, odour, etc. Do you feel that you evacuate your bowels completely during each bowel movement?
26. Liver and Gallbladder: Select any of the below that refer to you currently
Pain under right side of ribcage
Frequent skin rashes
Bitter metallic taste in the mouth
Bowel movements painful or difficult
Low energy, weakness or exhaustion
Upset from greasy or fatty foods
Blood in urine
Difficult urination
Dry, flaky skin or hair
Nausea
Frequent headaches
Pain between shoulder blades
General feeling of poor health
Aching muscles
Frequent use of laxatives
History of gall bladder issues
History of hepatitis
History of jaundice
Sneezing attacks
Itchy skin
Stools light coloured
Frequent kidney/bladder infections
Incomplete bladder emptying
Kidney stones
Lower back pain
Legs nervous at night, spasms or involuntary twitching
Poor memory
Spinal arthritis
Swollen feet or legs
Water retention
Weakness of the knee
27. Bones and Minerals: Select any of the below that refer to you currently
Hip and joint pain
Receding gums
Tendency towards slouching
Bone loss/osteoporosis
Crunching or creaking joints
28. Thyroid (Endocrine System): Select any of the below that refer to you currently
Insomnia
Can't gain weight
Highly emotional
Night sweats/shakes
Inward trembling
Increased appetite without weight gain
Eyelids and face twitch
Can't work under pressure
Nervousness
Intolerance to heat
Flush easily
Thin, moist skin
Heart Palpitations
Pulse fast at rest
Irritable and restless
Slow pulse, below 65
Decrease in appetite
Ringing in ear (tinnutis)
Dry or scaly skin
Mental sluggishness
Headaches upon rising
Frequency of urination
Increase in weight
Fatigue easily
Sleepy during the day
Constipation
Hair coarse/falls out
Impaired hearing
Reduced initiative
Hair growth on face (women)
29. Pituitary (Endocrine system): Select any of the below that refer to you currently
Increased/decreased sugar tolerance
Low blood pressure
Headaches
Failing memory
Increased sex drive
Bloating of abdomen
Weight gain around hips
Tendency to ulcer
Menstrual disorders
Lack of menstruation
Reduced sex drive
30. Adrenals: Select any of the below that refer to you currently
Dizziness
Hot flushes
Hair growth on face/body (female)
Sugar in urine, not diabetes
Headache
Increased blood pressure
Masculine features
Asthma
Chronic fatigue
Respiratory disorders
Poor circulation
Swollen ankles
Bowel disorder
Low blood pressure
Weakness, dizziness
Allergies
Brown spots or bronzing skin
Crave salt
Arthritic tendencies
Nails weak, rigid
Exhaustion
31. Immunity: Select any of the below that refer to you currently
Child with chronic immune disturbances
Enlarged glands
Skin irritation or eczema
Chronic/acute stress
Swollen lymph nodes
Recurrent minor infections
Throat infections
Poor wound healing
Slow recovery from illness
Boils of styes
Cold/flu frequently
Bumpy skin on arms
Inflammed or bleeding gums
Cough with mucus
Swollen tongue
Dark areas under eyes
Sore throat
Post-nasal drip
Ear-aches and infections
Herpes/cold-sores
32. Respiratory System: Select any of the below that refer to you currently
Allergies
Wheezing
Shortness of breath
Smoking
Grief/sadness/crying
Chest pain
Asthma
Chronic cough
Excessive mucus
Cold/flu
Skin issues
33. Filtering System: Select any of the below that refer to you currently
Bitter metallic taste in mouth
Blood in urine
Bowel movements difficult or painful
Difficult urination/starting the stream
Dry flaky skin
Fear/feeling insecure
Feelings of nausea
Frequent headaches
Frequent urination
Frequent use of laxatives
Frequent skin rashes
Frequent kidney/bladder infections
Gout
High blood pressure
History of gallbladder issues
History of hepatitis
Incomplete emptying of bladder
Itchy skin/worse at night
Kidney stone/problems
Legs nervous at night/involuntary twitching
Low sex drive
Low blood pressure
Lower back pain
Pain between shoulder blades
Pain under right side of rib cage
Poor memory
Upset from greasy/fatty foods
Spinal arthritis
Stools light coloured
Swollen feet/legs
Water retention
Weakness of the knee
34. Female: Select any of the below that refer to you currently
Section not applicable
Long standing depression
Low feelings before menstruation
Headache before or during menses
Menopausal hot flashes
Pre-menstrual tension
Painful breasts
Too frequent menstruation
Migraine headache
Obsessive dietary habits
Vaginal discharge
Uterine fibroids/cysts/PCOS
Retaining fluid during period
Overwhelmed
Diminished sex drive
Painful menses
Easily fatigued
Acne worse at menses
Menses scanty or missing
Periods excessive/long
Vaginal dryness
Hysterectomy
Breast cysts/lumps/mastitis
Miscarriage
Frequent thrush
Difficulty conceiving
Stress from abortion
35. Male: Select any of the below that refer to you currently
Section not applicable
Urination difficult or dripping
Tire too easily
Prostate disorder
Pains on inside of legs
Legs nervous at night/involuntary twitching/spasms
Overwhelmed
Diminished sex drive
Lack of energy
Migraine headache
Incomplete bowel movements
Frequent night urination
Feeling inadequate
36. Environment: Select any of the below that refer to you currently
Exposure to fumes e.g. paint, hair salon, car, sealants etc
Skin disorders e.g. psoriasis, hives, eczema
Live near power lines, mobile mast
Mercury fillings
Use of household chemicals
Use pesticides
Loss of hair
PC work
37. Nutritional History: Select any of the below that refer to you currently or in the recent past
Breast fed
Vegetarian
Vegan
Pescatarian
Fat restricted diet
Salt restricted diet
Calorie restricted diet
History of yo-yo dieting
Obesity or history of obesity
39. How many portions of fruit do you eat per day?
None
1-2
3-5
More than 5
40. How many portions of vegetables do you eat per day?
None
1-2
3-5
More than 5
41. How much water do you drink per day?
None
500ml
500ml-1L
1L-2L
More than 2L
42. What type of water do you drink?
Tap
Bottled
Filtered
Purified e.g. reverse osmosis, carbon filter
43. What other beverages do you consume? Soft drinks, fruit juice, squash, tea etc. How much coffee do you consume per day?
44. On average, how much alcohol do you consume in units per week?
45. Do you smoke or have ever smoked? Please state amount and frequency, when stopped and form cigarette, cigars, vape etc
46. Please state amount and type of sport and exercise you undertake per week.
47. Please give any information regarding stress and anxiety in your daily life, including any mental health issues. Include details on your job, working hours, home life, relationships, regular travel and any other stressors.Have there been any major life events recently, bereavement, relationship break-up, moving home, job loss etc?
48. Please state any foods that you would find difficult to cut out of your life
49. Please include any other relevant information that you wish to share
50. Do you confirm that you have requested coaching, nutritional/functional medicine support from ..... under supervision
Yes
No
51. Statement of declaration: I will use the information that you give on this form to provide you with lifestyle and functional nutritional advice to help with your condition. I may seek further information from your doctor by telephone or in writing. Please read and sign the following declaration: I declare that to the best of my knowledge the answers I have given to the questions in this form are full and correct. I agree to notify you of any significant changes to my health. I have read and accepted this document. All data provided is CONFIDENTIAL and will not be shared without my consent. Please Sign below
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