Health Questionnaire – Dundee Herbal Clinic

This Questionnaire will take around 30 mins to fill out. It can seem daunting to answer so many questions but your optimal health and wellness is my primary concern and the answers you give here will help me to make sure that you are on the correct course of treatment.

Please don't worry if you don't know the answers to some questions. Just fill out as much as you can.

Some questions may be repeated twice in different sections. Please do your best to fill out each section, even if it is a duplicate answer.

Personal Details

Name

Address

Email

Date of Birth

Occupation

Phone Number

Next of Kin and Contact Number

GP Name and Address

Presenting Information

What are your major health concerns at present?

Have you had any recent diagnoses by a health care professional

If yes, please provide details

What do you hope to achieve while working with Dundee Herbal Clinic?

Have you had a blood test or any other investigations in the last 12 months?

If yes, please provide details and if possible bring the results with you to your consultation.

Please list any medications you are currently taking.

Have you seen a herbalist or nutritionist before?

Health History

How many days a week do you exercise?

What is the intensity of this exercise?

Do you follow a specific way of eating?

How much water do you drink a day

Do you smoke?

Do you drink alcohol?

Do you use recreational drugs?

Are you comfortable with the amount you smoke, drink alcohol or use recreational drugs?

Do you crave certain foods? If so, specify foods:

When was the last time you took antibiotics?

Please list any nutritional or herbal supplements you are currently taking

Please list any major health issues in the past including surgeries

Family Health History

Please list any major conditions / illnesses that the following people have or had

Mother, Father, Paternal Grandparents, Maternal Grandparents, Siblings, Children.

Health Appraisal

Your answers to this section of the questionnaire will assist us in gaining information about your current symptoms and health concerns and help us to track changes over the coming months. Please answer all questions, in each section. Write Yes or no and describe the frequency of your symptoms over the previous month.
You may note that some questions are repeated throughout the questionnaire. We would appreciate it if you can answer all questions, as this will ensure the most accurate interpretation of your results. You may however leave a question blank if you are unsure of the answer.

Gastro Intestinal - Stomach Hypo-acidity

How frequently do you experience:

Indigestion

Excessive belching or burping

History of anemia

Bloating or fullness commencing during or directly after a meal

Sensation of food sitting in the stomach for a long time post meal

Loss of appetite or nausea

Stomach Hyperacidity

How frequently do you experience:

Stomach pain 1-4 hours after eating

Indigestion from spicy / fatty foods, alcohol or coffee

Heartburn aggravated by lying down or bending forward

Vomiting blood or vomitus has appearances of coffee grounds

Feeling hungry 1-2 hours after eating

Stomach discomfort or pain in response to strong emotions, thought or the smell of food.

Antacids, carbonated beverages, milk, cream or food relieve the above symptoms

Black tarry stools

Small intestine/pancreas

How frequently do you experience:

Indigestion bloating and fullness for several hours after eating

Abdominal cramps and aches

Excessive passage of gas

Constipation

Stools smelly or greasy and stick to the toilet bowl

Dry flakey skin and brittle hair

Nausea and / or vomiting

Diarrhoea

Alternation constipation and diarrhoea

Undigested foods in stools

Black tarry stools

Difficulty gaining weight

Colon

How frequently do you experience:

Lower abdominal pain and cramping

Excessive gas or bloating

Diarrhoea

Alternating between constipation and diarrhoea

Extremely narrow stools

Red blood with bowel movement

lower abdominal pain relieved by passing gas or stool

Certain foods aggravate lower abdominal pain

Constipation

Sensation of incomplete emptying of the bowel

Mucus or pus in stools

Rectal pain or cramps

Liver / Gall Bladder / Pancreas

How frequently do you experience:

Upper abdominal pain or pain under ribs

Excessive belching or gas

Loss of appetite

Unexplained itchy skin

Pale clay-coloured stools

Fluid retention, oedema

Loss or thinning of hair

Dry flakey skin or dry hair

Bloating or feeling of fullness after eating

Fatty foods cause indigestion or nausea

Nausea and / or vomiting

Yellowish discolouration of skin or eyes, dark coloured urine

Fatigue or weakness

Easy bruising or bleeding eg. gums

Red skin, particularly of palms

Symptoms of under-active Thyroid

How frequently do you experience:

Fatigue, sluggishness

Swelling or tightness in the front of neck

Dry skin and hair

Gaining weight or decreased appetite

Difficulty concentrating, poor memory.

Infertility

Feeling cold or intolerant to cold

Constipation

Puffy face, hands or feet

Low mood

Low libido

Heavier and more frequent menstrual periods

Symptoms of over-active Thyroid

How frequently do you experience:

Fatigue, noticeable weakness in limbs

Diarrhoea

Palpitations

tremor

Visual disturbance, problems with eyes or development of staring gaze

Light infrequent or absent menstrual periods

Feeling or intolerance to heat

Weight loss, possibly with increased appetite

Nervousness, irritability or restlessness

Insomnia

Low libido

Stress, Fatigue and Adrenals

How frequently do you experience:

Feeling stressed, nervous or tense and unable to relax

Feeling overwhelmed unable to cope

Fatigued or tire easily

Difficulty staying awake during the day

Palpitations or chest pain

Change in appetite

Feeling irritable or oversensitive

Low mood, mood swings

Need a stimulant eg, coffee, tea or sugar as a pick me up

Find it hard to get up and going in the morning

Insomnia

Nausea or dizziness

Low immunity

How frequently do you experience:

Frequent colds and flu

Diarrhoea

Nasal congestion or discharge

Cough with mucus

Inflamed or bleeding gums / swollen lips or tongue

Excessive loss of hair

Frequent infections

Ears continuously draining ears

Sore throat

Cold sores

Wounds heal slowly

Neck, armpit and groin swelling

Allergy

How frequently do you experience:

Migraine or head ache

Dark circles under eyes

Localised or generalised itchiness

Clear watery discharge from nose or eyes

Irritability or fatigue

Sensitivity to light

Swollen eyes, lips, or other body parts

Rashes or eczema

Sneezing, coughing or wheezing

Certain foods worsen symptoms or cause palpitations

Skin

How frequently do you experience:

Acne

Psoriasis

Poor wound healing

Dandruff

Eczema

Dermatitis

Dry skin

Musculoskeletal

How frequently do you experience:

Aches and pains

Joint swelling

Restless legs

Disc herniation / protrusion

Joint pains

Muscle cramps / twitching

Headaches

Sciatica

Cardiovascular

How frequently do you experience:

High blood pressure

High cholesterol

Dizziness

Breathlessness

Palpitations

Easy bruising

Nose bleeds

Low blood pressure

Arrhythmia

Chest pain

Leg pain on extension

Cold hands and feet

Varicose veins

Detox Capacity

Do you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents? Include details:

Are you overly sensitive to anything such as alcohol, perfumes or strong fragrances?

For Women Only

Indicate cycle length / duration of bleed

Do you use pads, tampons, moon cup or other?

Are you considering or planning to conceive in the next 12 months?

How frequently do you experience?

PMS / PMT

Breast tenderness

Irregular cycles

Heavy bleeding during periods

Thrush or vaginal itching

Painful periods

Bloating

Blood clots in period

Bleeding between periods

For Men Only

Have you ever had a prostate check? if so, when?

Do you have difficulty urinating?

Do you have poor hair or beard growth?

Do you experience pain or discomfort in your groin or testes?

Do you have difficulty sustaining an erection?

Have you ever contracted a sexually transmitted infection?

Personal Details

Presenting Information

Health History

Family Health History Please list any major conditions / illnesses that the following people have or had

Please list any major conditions / illnesses that the following people have or had

Gastro Intestinal - Stomach Hypo-acidity How frequently do you experience:

How frequently do you experience:

Stomach Hyperacidity How frequently do you experience:

How frequently do you experience:

Small intestine/pancreas How frequently do you experience:

How frequently do you experience:

Colon How frequently do you experience:

How frequently do you experience:

Liver / Gall Bladder / Pancreas How frequently do you experience:

How frequently do you experience:

Symptoms of under-active Thyroid How frequently do you experience:

How frequently do you experience:

Symptoms of over-active Thyroid How frequently do you experience:

How frequently do you experience:

Stress, Fatigue and Adrenals How frequently do you experience:

How frequently do you experience:

Low immunity How frequently do you experience:

How frequently do you experience:

Allergy How frequently do you experience:

How frequently do you experience:

Skin How frequently do you experience:

How frequently do you experience:

Musculoskeletal How frequently do you experience:

How frequently do you experience:

Cardiovascular How frequently do you experience:

How frequently do you experience:

Detox Capacity

For Women Only

How frequently do you experience?

For Men Only

Family Health History

Please list any major conditions / illnesses that the following people have or had

Gastro Intestinal - Stomach Hypo-acidity

How frequently do you experience:

Stomach Hyperacidity

How frequently do you experience:

Small intestine/pancreas

How frequently do you experience:

Colon

How frequently do you experience:

Liver / Gall Bladder / Pancreas

How frequently do you experience:

Symptoms of under-active Thyroid

How frequently do you experience:

Symptoms of over-active Thyroid

How frequently do you experience:

Stress, Fatigue and Adrenals

How frequently do you experience:

Low immunity

How frequently do you experience:

Allergy

How frequently do you experience:

Skin

How frequently do you experience:

Musculoskeletal

How frequently do you experience:

Cardiovascular

How frequently do you experience: