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Thank you

Thank you for booking an appointment with us, we look forward to working with you. We now just would ask you to complete the health profile form which is vital for the low cost clinic.

You can fill the form directly online or you can download it HERE and email it back to LowCost@NutritionClinic.co.uk at least 48hours before the appointment.

We look forward to supporting you in your health journey.

HEALTH PROFILE

  • Consultation Details

  • Date Format: MM slash DD slash YYYY
  • Client Details

  • Date Format: MM slash DD slash YYYY
  • General Practitioner’s Details

  • (two primary goals)
  • (since when, duration, location, sensations, previous treatments, CLAMPS)
  • (Childhood illness, vaccinations, operations or medical interventions, previous accidents, recurrent illnesses)
  • (name of the medication/drug, reason for taking it and dosage)
  • (which therapies used before, name of the supplement, reason for taking it)
  • (father, mother, sisters, brothers, grandfather from father and mother, grandmother from father and mother, uncles)
  • (acid reflux, halitosis, bloating, burping, diarrhoea, constipation, haemorrhoids, abdominal pain, anal pruritus, flatulence)
  • (headaches/migraines, visual disturbance, dizziness, vertigo, weakness, fainting, anxiety, poor memory, poor concentration, depression, sleep disturbances, night sweats, vivid dreams, fears)
  • (thyroid and adrenal dysfunction, blood sugar fluctuations, cravings, frequent urinations, weight gain or loss, goitre, present stress levels or previous stress levels, energy levels, fatigue, heart palpitations, irritable and restless, mental sluggishness, decrease or increase in appetite, nervousness, intolerance t heat, thin/moist skin, dry/scaly skin, enlarged gland, lymph nodes swelling, exhaustion, nails weak/rigid, crave salt, brown spots or bronzing skin, chronic fatigue, asthma, poor circulation)
  • (fertitlity history, presence of diagnosis diseases, premenstrual details, menses, infections, thrush, STD’s, menopause, libido levels, migraine, painful breasts, vaginal discharge, vaginal dryness, hysterectomy, acne worse at menses, overwhelmed, lack of fulfilling relationship, prostate, erectile dysfunction, frequency/difficult of urination, financial stress, lack of energy)
  • (food intolerances, food allergies, urticaria, hay fever, cold sores, wound healing time, eczema, asthma, presence of autoimmune disease, frequent cold/flus, swollen tongue, sore throat, dark areas under the eyes, slow recovery from illness, anaemia, easily bruised, enlarged spleen)
  • (asthma, wheezing, bronchitis, postnasal drip, mucus or sputum, sinusitis, shortness of breath, ear infections, persistent cough, dry throat, wheezing)
  • (pain, burning, frequency, haematuria, difficulty, colour, smell, UTI’s, water retention, gout, low blood pressure, poor memory, lower back pain, spinal arthritis)
  • (chest pain, shortness of breath, palpitations, oedema, fainting, varicose veins, cold extremities, Blood Pressure, tinnitus, smoker, swollen ankles, sigh frequently, air hunger, experience loss/fatigue)
  • (hip/joint pain, stuffiness, joint swelling, back pain, injuries, spams, cramps, time recovery from exercise, crunching/creaking joints, bone loss/osteoporosis)
  • (Acne, dry/oily skin, eczema, dermatitis, psoriasis, rashes, fungal infections, sensitivity, brand of cosmetics/skincare products used)
  • (cooking habits, shopping habits, dietary type, vegetarian, vegan)
  • (work/life balance, type of work, presence of stressor, relaxation, hobbies and interests, exercise type - frequency and duration, smoking, recreational)
  • EXCLUSIVELY FOR NUTRITIONAL CONSULTATIONS ONLY

    IF YOU ARE BOOKING A HOMEOPATHIC SESSION THEN PLEASE SKIP THIS FOOD DIARY.

  • TWO DAY FOOD DIARY BELOW

    Write down all the foods and drinks consumed over the next three days, two weekdays and one weekend day, Please, add as much information as possible including time eaten, whether food is fresh, packaged.

  • On waking

  • Breakfast

  • Snacks

  • Lunch

  • Snacks

  • Dinner

  • FORM OF CONSENT TO TREATMENT:

  • By submitting this form you agree to our GDPR terms and Privacy Policy.

FORMS FOR DOWNLOAD

Health Profile - Students
GDPR - Students
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