Sheeba The Nutritionist

Step 1

Basic Details

Full Name : *

Select Gender : *

Occupation :

Date of Birth : *

Weight(kg) :

Height(cm) :

Blood Type :

Blood Pressure :

Relationship Status :

Number Of Children :

Are you pregnant,planning or lactating :

Email Address : *

Address :

Phone:

Country :

Postal Code :

What are your immediate and long-term health goals ?

Primary health problems/symptoms:

Name of health issue	Mild/moderate/severe	Year of onset

Was the onset of your symptoms fairly sudden or gradual?
What do you believe or suspect triggered your symptoms?

Step 2

Present medications/supplements/herbs:

Include contraceptives & medications taken regularly (e.g. antacids or aspirin).

Name of product	Dose (e.g. 30 mg)	Duration taken (e.g. 6 months)	Reason(s) (e.g. for acne)	Does it help? (no, slightly, moderately or completely)

Are you undergoing any other treatments or therapies? e.g. counselling, meditation, acupuncture, etc.

Name of treatment/therapy	Duration	Does it help? (no, slightly, moderately, markedly)

DRUG HISTORY

Name of Drug/s	Dosage & Frequency	Duration Taken	Reason for prescribed/self-administered drugs

Step 3

Any past/current use of: Laxatives, Antacids, Painkillers, Sleeping Pills, Oral Contraception, Antibiotics, Vitamins/Minerals Supplements, Other?

Name of Product	Type	Duration Taken	Past/Current Use

ALLERGIES

Known allergies to drugs, foods, environment etc - past and present

Chemical Sensitivities

FAMILY HISTORY

Major health problems in the family

LIFESTYLE

Describe your Home Situation, Work Situation, Hobbies/Pastimes, Recreational drugs usage

EXERCISE HABITS

Describe duration, intensity, frequency

Step 4

REVIEW OF BODY SYSTEMS

NERVOUS SYSTEM

(Please check and choose all that apply)

Energy Level from 1 to 10 :

Morning

Mid-day

Afternoon

Evening

DIGESTIVE SYSTEM

(Please check and choose all that apply)

	Poor/Large Appetite	Nausea/Vomiting	Weight Change- Increase/Decrease
	Flatulence/Bloating/Abdominal Pain	Indigestion/Reflux/Acidity	Dental Problems
	Difficulty swallowing	Rectal bleeding/Haemorrhoids	Unusual Stool Colour/ Inconsistency/ Irregularity/ Diarrhoea/ Constipation/ Pain/Blood
Bowel movements			/day

IMMUNITY

(Please check and choose all that apply)

	Recurrent Infections		Night sweats		Recurrent/Chronic conditions
	Slow wound-healing time		Frequency/Length of colds/flus

RESPIRATORY SYSTEM

(Please check and choose all that apply)

Earache/Tinnitus/Hearing Loss	Sputum/Post nasal drip	Cough
Recurrent Infections	Catarrh/Sinus	Sore Throat
Wheeze/Difficulties-inhaling or exhaling/Tightness of chest

URINARY SYSTEM

(Please check and choose all that apply)

Frequency/Urgency	Pain/Burning/Dysuria	Haematuria - blood in urine
Loin Pain	Difficulty Starting	Weak Stream/Dribbling/Incontinence
Urine Character-Colour/Quality/Smell

Step 5

CARDIOVASCULAR SYSTEM

(Please check and choose all that apply)

MUSCULOSKELETAL

(Please check and choose all that apply)

	Joint Pain/Stiffness		Joint Swelling		Back/Neck Pain
	Injuries		Spasms /cramps

SKIN

(Please check and choose all that apply)

REPRODUCTIVE (MALE/FEMALE)

(Please check and choose all that apply)

Menarche Cycle Length - Regularity/Duration	Menopause- Peri/Post	Loss of libido
STDs	Infertility/Impotence/Dysfunction	Pregnancies/Miscarriages/Terminations
Benign prostate enlargement (BPH)	Cycle Length - Regularity/Duration
Dysmenorrhoea/Clotting/Colour/Amount, P.M.S (type)

ENDOCRINE

(Please check and choose all that apply)

	Poor temperature regulation (aversion to cold etc.)		Poor energy levels throughout the day (fatigue)		Weight gain/loss
	Goitre		Loss/growth of body hair

DIET

(time, what was consumed, any reactions observed i.e. bloating, mood changes etc)

Do you follow any specific dietary guidelines (i.e. vegetarian, kosher, etc)?

Step 6

How often do you consume the following: (0: never, 1: 1-2 x a month, 2: weekly, 3: 3x week, 4:daily) Please choose

Sugar	Dairy Products	Caffeine Drinks
White bread/pasta/ rice/noodles	Chicken	Fresh fruits
Table salt	Fish/seafood	Vegetables
Fried foods	Red meat	Green salads

How many glasses of water do you consume daily?

Do you consume alcohol? Yes/No. If, so how many standard drinks per week?

Do you smoke? Yes/ No. If so, how many cigarettes per day?

Foods that you have an aversion or sensitivity to:

CARBOHYDRATE METABOLISM

(Please check all that apply)

Hormonal/ Steroid treatments

What is 6 + 7 ? =

I agree to the terms and condition & Privacy Policy.

	Childhood Diseases
	Accidents
	Operation/Surgery
	Medical results i.e. blood tests
	Major recurrent Illnesses(i.e. Hepatitis, Jaundice, Diabetes)

	General Health
	Hospitalisations
	Immunisations
	Dental Metal Fillings: How Many?
	Hormonal/ Steroid treatments

	Sleep Disturbance/ Night sweats/Dreams		Headache/Migraine		Visual Disturbance
	Numbness/tingling		Depression		Anxiety/Stress
	Dizziness/ Vertigo/ Weakness		Fainting/Fits		Mood Changes/ Fluctuating emotions
	Poor Memory/Concentration	Sleep patterns - difficulty/easy going to sleep, difficulty/easy waking
Sleep		Describe quality		Stress Level from 1 to 10

Chest Pain	Shortness of breath	Palpitations
Oedema/swelling	Varicose Veins	Cold Extremities
Blood Pressure

	Acne/Dry/Oily		Rashes		Herpes
	Eczema/Psoriasis		Fungal Infections

	Sugar/Chocolate Cravings		Shakiness between meals		Irritability
	Grazer		Emotional Eater		Sleepiness after eating

Step 1

Basic Details

Primary health problems/symptoms:

Step 2

Present medications/supplements/herbs:

Include contraceptives & medications taken regularly (e.g. antacids or aspirin).

Are you undergoing any other treatments or therapies? e.g. counselling, meditation, acupuncture, etc.

Previous Medical History

(Please check and fill detail for all that apply).

DRUG HISTORY

Step 3

Any past/current use of: Laxatives, Antacids, Painkillers, Sleeping Pills, Oral Contraception, Antibiotics, Vitamins/Minerals Supplements, Other?

ALLERGIES

FAMILY HISTORY

LIFESTYLE

EXERCISE HABITS

Step 4

REVIEW OF BODY SYSTEMS

NERVOUS SYSTEM

(Please check and choose all that apply)

Energy Level from 1 to 10 :

DIGESTIVE SYSTEM

(Please check and choose all that apply)

IMMUNITY

(Please check and choose all that apply)

RESPIRATORY SYSTEM

(Please check and choose all that apply)

URINARY SYSTEM

(Please check and choose all that apply)

Step 5

CARDIOVASCULAR SYSTEM

(Please check and choose all that apply)

MUSCULOSKELETAL

(Please check and choose all that apply)

SKIN

(Please check and choose all that apply)

REPRODUCTIVE (MALE/FEMALE)

(Please check and choose all that apply)

ENDOCRINE

(Please check and choose all that apply)

DIET

(time, what was consumed, any reactions observed i.e. bloating, mood changes etc)

Step 6

How often do you consume the following: (0: never, 1: 1-2 x a month, 2: weekly, 3: 3x week, 4:daily) Please choose

CARBOHYDRATE METABOLISM

(Please check all that apply)