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(questionnaire page - link from health check page:)

The Ashdown Clinic
Helpline number: 01906 577 7077

Welcome to the Ashdown Clinic Health Check questionnaire.
Completing the questionnaire will help you identify your nutritional requirements
and gain a fuller understanding of your general health needs. There are seven
zones to fill in. Please allow at least ten minutes to answer the questions.
Once complete, please follow the instructions at the end of the questionnaire.
ZONE 1
Personal details

Note: all details on this questionnaire will be held private and confidential.

Please answer all questions as appropriate.
Please state
Surname ____________________________________________ First name ___________________________________________ Date of birth __________________________________________ Height _____________ Weight _____________ (For office use only: BMI: ) Occupation ______________________ Contact address _______________________________________ Postcode _____________ Contact telephone number ______________ GP's name and address _________________________________ _____________________________________________________ Postcode _____________ GP's telephone number ______________ Do you give permission for your GP to be contacted? Is your GP aware of your intention to see a nutrition consultant? Yes [box] No [box] Have you seen a nutrition consultant, or any other health professional, before regarding your current symptoms? Please state your main reason(s) for seeking nutritional support Are you hoping to alleviate a particular symptom or ailment? The Ashdown Clinic
Helpline number: 01906 577 7077

ZONE 2

Personal health profile

Starting with your most current health problems, please list in the space provided all
significant health problems that you have encountered over your lifetime. Indicate,
where appropriate, the duration, timing and management of the health problem.
Example:
Health Problem


Health Problem
Duration
Management

(four lines)

Hereditary Profile

Do you have any children? If so, state age and sex _________________________
Are there any illnesses that they suffer from? ______________________________
How many brothers and sisters do you have? State age and sex ______________
What illness is/was your father prone to? _________________________________
What illness is/was your mother prone to? _________________________________
The Ashdown Clinic
Helpline number: 01906 577 7077

ZONE 3
Symptom assessment

Below is a list of symptoms associated with nutritional insufficiency. Please underline
the symptoms/ailments you regularly suffer from. You will find that some symptoms are
repeated. Please underline them each time they appear.
Mouth ulcers
Acne
Frequent colds and infections
Psoriasis
Dull-looking skin
Pre-menstrual syndrome (PMS)
Frequent throat infections
Family history of lung or oral cancer
Poor night vision
Alcohol intolerance
Sugar craving
Fatigue
Tender muscles
'Prickly' legs
Lack of energy
Alcoholism
Chronic fatigue syndrome
Fibromyalgia (non-insulin dependant)
Type II diabetes
Epilepsy
Cracks at side of the mouth
Gritty eyes
Fatigue
Sensitivity to bright light
Cataracts
Sore tongue
Lack of energy
Lack of energy
Irritability
Fatigue
Poor memory
Depression
Burning feet
Tender heels
Fatigue
Lack of energy Teeth grinding Exhaustion after light exercise Pre-menstrual syndrome (PMS) Cardiovascular problems Fatigue Water retention Lack of energy Depression Irritability Infrequent dream recall Lack of energy Poor memory Fatigue Prematurely greying hair Poor appetite Cardiovascular problems Fatigue Mouth ulcers Memory loss Frequent colds and infections Bleeding or tender gums Easy bruising Arthritis Red pimples on skin Slow wound healing Chronic stress Cardiovascular problems Haemorrhoids Chillblains Varicose veins Arthritis Broken veins Fluid retention Premature skin ageing Puffy eyes Blood shot eyes Rhinitis Hay fever Family history of cancer Adverse menopausal symptoms Osteoporosis Cardiovascular problems Cancer of the breast/prostate/cervix Heart disease Leg pain Cataracts Muscular degeneration Infertility Painful breasts Osteoporosis Muscle cramps or tremors Tooth decay Pre-menstrual syndrome (PMS) Osteoporosis Pre-menstrual syndrome (PMS) Fluid retention Fatigue Under-eye twitch Muscle aches and pains Anxiety or tension Insomnia Cardiovascular problems Restlessness Painful breasts Sugar craving Chronic stress Chronic fatigue syndrome Fibromyalgia Asthma Type 1 diabetes (insulin dependant) Type II diabetes (non-insulin dependant) High blood pressure Fits or seizures Hair loss - diffuse Fatigue Excessive menstrual bleeding Breathlessness Listlessness 'Spoon-shaped' nails Anaemia Acne Frequent infections White flecks in more than 2 finger nails Infertility Sugar craving Stretch marks Poor growth (children) Poor sense of taste and smell Slow wound healing History of miscarriage Type II diabetes (non-insulin dependant) Anorexia nervosa/bulimia Growing pains Poor sense of balance Sore knees Premature skin ageing Fits or seizures Thyroid abnormality Cataracts Frequent infections Premature skin ageing Infertility Cardiomyopathy Emphysema Family history of cancer Cold sweats Dizziness or irritability after 5 hours without food Need for frequent meals Need for frequent caffeine Cold hands and feet 'Addicted' to sweet foods Poor energy levels Type II diabetes (non-insulin dependant) Thyroid abnormality (underactive) Weight gain Apathy Sensitivity to cold Muscle weakness Heart problems Psoriasis Asthma Irritable bowel syndrome Poor memory ADHD Frequent infections Dry eyes Dull/dry skin Pre-menstrual syndrome (PMS) Breast cysts Fluid retention Infertility Eczema Rheumatoid arthritis Neutropenia Thinning bones Heart beat abnormalities Emphysema The Ashdown Clinic
Helpline number: 01906 577 7077
ZONE 4
Please circle the number that best describes your response

Key:
0 = not at all
1 = a little
2 = moderately
3 = a lot
4 = continually
Feeling low on energy
Sore or swollen lymph glands under your arms 0 Having to do things slowly to ensure correctness 0 The Ashdown Clinic
Helpline number: 01906 577 7077
ZONE 5
Please circle the YES/NO boxes as appropriate
Women-only questions

What age did you start your monthly period?
What age did your monthly periods cease?
Do you, or have you taken the contraceptive pill?
Have you taken hormones for any other reason? Have you ever had an abnormal smear result?
Obstetric history

Are you pregnant or planning for a baby?
Have you ever experienced a miscarriage? Have you ever received treatment for infertility? Did you experience any complications in pregnancy? Did you experience any complications during labour? Did you experience any difficulties breast feeding?
Please underline those problems that you currently suffer from:

Benign breast lamps
The Ashdown Clinic
Helpline number: 01906 577 7077

ZONE 6

These questions are for men only and help your practitioner to specifically target any
hormonal related health problems.

Please underline those problems from which you currently suffer.

altered urine flow
benign prostate hyperplasia
low sperm count/motility
prostate cancer
infertility
dry skin, face and hands
undescended testes
prostatis
testicular cancer
impotence
The Ashdown Clinic
Helpline number: 01906 577 7077

ZONE 7
DIETARY ANALYSIS

Please tick the questions to which you would answer 'yes' or enter the 'number of times'
you eat the food referred to in the question.

1. Were you breast fed as an infant?
2. Was a significant percentage of your diet as a child high in fatty foods and sugar? 3. Do you go out of your way to avoid foods containing preservatives and additives? 4. Do you avoid foods which contain sugar? 5. How many teaspoons of sugar do you add to food/drinks each day? 8. How many coffees do you drink each day? 9. How many cups of tea do you drink each day? 10. If you smoke, how many cigarettes do you smoke per day? 11. How many times a week do you have meals containing fried food? 12. Do you eat salmon, mackerel or herring each week? 13. How many times a week do you eat chocolate confectionery? 14. If one portion of fruit/vegetables is the equivalent of a medium-sized banana, how many portions a day of fruit and vegetables do you eat? 15. Do you normally eat white rice and white bread? 16. How many times a week do you eat pulses eg lentils and chickpeas? 17. How many slices of bread or rolls do you eat each week? 18. How many pints of milk do you drink in a week? 19. How many times a week do you eat red meat (beef, pork, lamb or game)? 20. How many times a week do you eat white meat (poultry, fish)? 22. How many glasses do you drink a week? 23. Do you avoid all animal products including dairy? 24. Do you use a water filter or drink bottled water instead of tap water? 25. How much water do you drink a day (not including tea, coffee etc)? 26. Do you frequently eat under stressful conditions or on the move? 27. How would you describe your appetite? The Ashdown Clinic
Helpline number: 01906 577 7077

Write down all the food and drinks consumed over the next two days, starting today.
Please add as much information as possible including quantities eaten, brand names, and
whether the food is fresh or packaged, refined or natural.

Day 1

Breakfast
Lunch
Dinner
Snacks/drinks
Day 2

Breakfast
Lunch
Dinner
Snacks/drinks
Are these two days representative of your usual eating habits? If not, what is a more usual
day?

Breakfast
Lunch
Dinner
Snacks/drinks
What nutritional supplements do you take daily on a regular basis?

Name of preparation
The Ashdown Clinic
Helpline number: 01906 577 7077

Thank you for completing the questionnaire.
If you would like to have your responses analysed, you can fax or post the
questionnaire to us with a consultation fee of £20. We will send you a
personalised health profile within two working days, which will advise you of any
changes you should make to your dietary habits and either suggest a programme
of supplements to take or confirm that you are already on the correct path to a
healthy lifestyle.
If, once you've read the profile we send you, you would like to proceed with a
three month programme, we will credit you with £10 towards its cost.
Please complete the following details.

Your name _________________________________________________
Your address _______________________________________________
__________________________________________________________
Your postcode ______________________________________________
Your telephone number _______________________________________
Your e-mail address __________________________________________*
(* If you include your e-mail address, we will e-mail confirmation of receipt
of your questionnaire to you.)
Payment details
If you are enclosing a cheque, please tick here
Please make out your cheque to Ashdown Clinic and include your guarantee number on the reverse. If you are paying by debit or credit card, please enter your details below. Credit card (please circle): Your name as printed on the card _____________________________________ Card number [4x4 boxes] Card valid from ___________ to (expiry date) __________ Switch issue number (Switch only) ___________________ Payment amount: Signature ___________________________ Date ______________
Thank you.
Please post your completed questionnaire to:
The Ashdown Clinic
54 Hatfield Road
Potters Bar
Herts EN6 1HT
or fax it to us on
01707 659978
Helpline number: 01906 577 7077
(UK only, 7am-7pm, Monday to Friday)

Source: http://www.ashdownclinic.co.uk/content/questionairre.pdf

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