HEALTH CHECK All details on this questionnaire will be held private and confidential. Please answer all questions as appropriate PERSONAL DETAILS
Date: ……………………………………….
Mrs Miss Master Dr Other ……………………………….
Surname: ………………………………. First name: ……………………………… Marital Status: ………………
Date of birth: ……………………………. Height: …………………………… Weight: …………………………….
Occuption: …………………………………………………………………………………………………………………
No. of dependents: ……………………. Age/sex of children: ………………………………………………………
Contact address: …………………………………………………………………………………………………………
……………………………………………………………………………………. Post code: ………………………….
Contact tel no: ……………………………. Emergency contact no: …………………………………………………
Medical doctor’s address: ……………………………………………………………………………………………….
……………………………………. Post code: ……………………… Doctor’s tel no: ………………………………
Do you give permission for your medical doctor to be contacted?
Is your medical doctor aware of your intention to see a dietary therapist?
Have you seen a dietary therapist or any other health professional before regarding
Do you give permission for a student or other professional to witness your consultation?
How did you hear about the clinic service? ……………………………………………………………………………
Please state your main reason/s for seeking dietary support ………………………………………………………. Please bring copies of any test results that you have had done previously. tick for yes Comments
Are you currently following a medically prescribed diet?
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Are you currently undergoing medical treatment?
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Are you pregnant, or aiming to become pregnant?
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Do you have a medically identified food allergy or intolerance?
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MEDICATIONS and SUPPLEMENTS. Please use a separate sheet if necessary. Please list below any prescribed drugs – current or in the past Medication
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Please list below any Over the Counter Medicines – current or in the past Medication
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Please list below any vitamins, minerals, herbs and other Supplements – current or in the past Supplement
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HEALTH ZONE CHECKS
Thorough completion of zone 1 enables your therapist to understand your health problems in the wider contact of your family history.
Is there any history of health problems or disease in your family?
tick for yes Comments
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Thorough completion of zone 2 provides your therapist with a comprehensive picture of your health history enabling a wholistic approach to your health.
Personal Health History Starting with the most current health problems please list in the space provided, all significant health problems that you have encountered in your lifetime. Indicate, where appropriate, the duration, timing and management of the health problem. Please continue on a separate sheet as necessary. Example: Health Problem Duration Management
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Zone 3 helps your therapist to identify some key symptoms that might need medical referral. This is not a definitive list. Please tick if yes to the following questions.
The following questions help your therapist to identify specific areas of imbalance in the body. Please tick if yes to the following questions.
Digestion + Assimilation Elimination Inflammation acne Toxic Load and Detoxification additives and preservatives
The following questions pertain to your allergifc history and/or potential for allergy Please elaborate as appropriate or tick box if yes to the following questions. Comments
Carry adrenalin injections for emergency use
Please list the foods and/or chemicals that you react to: .
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These questions are for women only and help your therapist specifically target any hormonal related problems. Please tick if yes to the following questions.
are you considering infertility treatment?
have you been diagnosed low/high thyroid?
do you have regular well-woman check-ups?
do you, or have you taken the contraceptive pill?
have you received infertility treatment?
do you, or have you taken a natural HRT?
have you taken hormones for any other reason?
age of first period? …………. years old
age of final period? …………. years old
These questions are for men only and help your therapist specifically target any hormonal related problems. Please tick if yes to the following questions.
The following questions help your therapist to identify the likelihood of adrenal and blood glucose imbalance. Please tick if yes to the following questions.
The following questions help your therapist identify stressors in your life. Please tick if yes to the following questions. zone 10 The following questions help your therapist target the health of your
circulation. Please tick if yes to the following questions.zone 11 Zone 11 helps your therapist identify more about your individual
body type. Please tick if yes to the following questions.
Zone 12 helps your therapist identify the level of body imbalance that
zone 12 you are currently experiencing or have experienced in the past. Please tick if yes to the following questions.
Please indicate any other diagnosed health problem you have or have had in the past? ………………………………………………………………………………………………………………………………
zone 13 Please answer the following questions relating your level of physical activity.
Explain the type of exercise, frequency, duration and place of regular exercise.
If you do not participate in regular exercise, please indicate the factors that prevent
you from doing so ……………………………………………………………………………………………… ………………………………………………………………………………………………
zone 14 Zone 14 helps your therapist understand your attitudes to diet and
your social circumstances in regard to food. Elaborate or tick for yes.
Are there any foods that you crave? . Are there any foods that you dislike? . What are your favourite foods? . Which foods would you find hard to give up? . Are you following a special diet, now or in the past? .
or have you experienced an eating disorder?
cater for a special diet in the family?
zone 15 Completing zone 15 helps your therapist identify the frequency of intake of specific foods
and pollutants. Please indicate the number of exposures as applicable.
How many cakes/pastries in a week? …………….
How many portion of (a portion = 80 grams)
*red meat = beef, pork, lamb and processed foods like ham, burgers and sausages
zone 16 Completing zone 16 gives your therapist a deeper insight into your
current dietary choices. Please tick if yes to the following questions.
frequently add prepared pickles and vinegar
eat mainly wholegrain bread, pasta & cereals?
regularly eat smoked and barbecued food?
zone 17 Completing zone 17 helps your therapist understand how you put your meals together.
INTERVENTION by INDIA – TRIPS Council June 2009 Agenda item ‘M’ – OTHER BUSINESS – Seizure of generic drug consignments at EC ports Madame Chair, When India and Brazil raised the issue of seizure of generic drug consignments at EC ports in the TRIPS Council meeting of March 3, we did not foresee that we will need to raise the issue again in today’s meeting. Going by EC’s interven
HEALTH CHECK 
zone 17 Completing zone 17 helps your therapist understand how you put your meals together.