Food Analyst Questionnaire All details on this questionnaire will be held private and confidential. Please answer all questions as accurately as possible to facilitate a nutritional programme being designed to best meet your needs. TITLE Other DATE Mr SURNAME OCCUPATION / CULTURAL ORIGINS AGE/SEX OF CHILDREN AGE/SEX OF SIBLINGS ANY ADULT DEPENDENTS? (If yes, please briefly elaborate) Briefly describe how you heard about this service? What is/are your main reasons for seeking dietary analysis? Miss Ms Master Dr FIRST NAME DATE OF BIRTH CONTACT DETAILS: ______________________________________________________ ______________________________________________________ ______________________________________________________ ___________________________________POST CODE _________ LANDLINE _____________________________________________ MOBILE _______________________________________________ EMAIL ________________________________________________ Mrs / HEIGHT WEIGHT MARITAL STATUS GP CONTACT DETAILS: __________________________________________ __________________________________________ ____________________POST CODE _____________ TELEPHONE ____________________________ ARE YOU CURRENTLY SEEING YOUR GP FOR ANY HEALTH PROBLEMS? YES / NO IS YOUR GP AWARE OF YOU SEEKING DIETARY SUPPORT? YES / NO DO YOU GIVE PERMISSION FOR YOUR GP TO BE CONTACTED? YES / NO HAVE YOU SOUGHT PROFESSIONAL NUTRITIONAL ADVICE IN THE PAST? YES / NO ARE YOU CURRENTLY SEEING ANY OTHER COMPLEMENTARY HEALTH CARE PRACTITIONER? YES / NO HAVE YOU SEEN A COMPLEMENTARY HEALTH OR ANY OTHER HEALTH PRACTITONER (OTHER THAN GP) IN THE PAST? YES / NO DO YOU GIVE PERMISSION FOR YOUR CONSULTATION TO BE OBSERVED BY A STUDENT OR OTHER PROFESSIONAL? YES / NO (delete as appropriate) Briefly describe what you hope to gain from dietary analysis. Briefly describe what you perceive as your strengths and limitations with regard to your current diet and lifestyle DISCLAIMER A Report will be compiled on the basis that the information given is true and valid. The compiled report however is not a replacement for any existing medical treatment. Your dietary analysis is based solely on the information you provided relating to your food intake. It does not take account of any dietary supplements, over-the-counter medications, use of the oral contraceptive pill, HRT or any other prescribed medications that you might be taking, e.g. antibiotics and antihistamines all of which can influence your nutritional requirements. However, the information provided in the text of your report will endeavour to inform you about such interactions with food. Your analysis will be an approximation of your nutrient intake based on respected software for UK foods ‘DietPlan6’. The software is based on McCance and Widdowson’s ‘Composition of Foods’ (6th Edition 2002) published by the Royal Society of Chemistry and the Food Standards Agency; and The Dietary Reference Values for Food Energy and Nutrients for the United Kingdom (2003) DOH. Both texts describe the strengths and limitations of the information provided. For example, to attain validity it would have to be assumed that there were no errors in the way the data was collected, analysed and interpreted. If considered appropriate, information will be provided in the text of the report to explain possible anomalies including concepts beyond those provided by acknowledged texts.  NS3UK 2005 PERSONAL HISTORY Starting with your current health concerns please outline all significant health problems that you can remember (including childhood events). ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Please list all Please list any nutritional supplements you currently REACTIONS TO MEDICINES/SUPPLEMENTS operations under take: anaesthetic with dates ___________________________________________ Have you ever reacted badly to an anaesthetic? __________________ ___________________________________________ If yes, please detail __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ Have you ever reacted badly to any medications? __________________ ___________________________________________ If yes, please detail __________________ ___________________________________________ _________________________________________ __________________ Have you taken supplements in the past? If yes, please _________________________________________ __________________ detail _________________________________________ __________________ ___________________________________________ Have you ever reacted badly to any supplements? __________________ ___________________________________________ If yes, please detail __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ _________________________________________ __________________ ___________________________________________ ___ Antibiotics: Childhood: minimal/moderate/considerable Adult: minimal/moderate/considerable Current minimal/moderate/considerable Please highlight why you have taken antibiotics? E.g. Ear/throat/chest/urinary/dental/acne/pelvic/following trauma or surgery? Other? Antifungals: E.g. for thrush, Athlete’s foot never/minimal/moderate/considerable (prescribed and/or over the counter)? Current OR Past? Antacids: Please describe (mainly over the counter)? (mainly prescribed)? ______________________________________________________________________________________________________________ Pain Killers: Please describe (mainly over the counter)? (mainly prescribed)? ______________________________________________________________________________________________________________ Contraceptive Pill: Please indicate whether you have taken the contraceptive pill for contraception and/or hormonal problems? Detail below your pattern of use of the contraceptive pill. E.g. Age 14-16 for period pains, Age 18-25 for contraception, Age 20-30 for acne __________________ ______________________________________________________________________________________________________________ Did you/Do you tolerate the contraceptive pill well? YES/NO If not, please detail side-effects experienced _________________ ______________________________________________________________________________________________________________ HRT: Similarly describe your use of HRT, and whether you tolerate/tolerated HRT well ____________________________________________ ______________________________________________________________________________________________________________ Antidepressants: Please describe in same format as above _________________________________________________________________ _____________________________________________________________________________________________________________ PLEASE LIST ANY OTHER MEDICATIONS TAKEN CURRENTLY OR IN THE PAST ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ FAMILY HISTORY Indicate as best you can which family members were/are prone to any of the following disorders: Grand parents GMM (maternal) GMP (paternal) or GFM (maternal) or GFP (paternal), parents M or F, Sibling B or S, Cousins (if known) CM (maternal) or CP (paternal), Children CHM (male) or CHF (female). Don’t know DK. SF for yourself ____________________ Addictive/Obsessive ____________________ Alzheimer’s disease ____________________ Artery disease ____________________ Asthma ____________________ Attention deficit ____________________ Autism ____________________ Cancer ____________________ Chemical Sensitivity ____________________ Chronic fatigue ____________________ Constipation ____________________ Depression ____________________ Diabetes ____________________ Disordered Eating ____________________ Eczema ____________________ Endometriosis ____________________ Epilepsy ____________________ Fibroids ____________________ Food Intolerance ____________________ Hayfever ____________________ Headaches ____________________ High blood pressure ____________________ High cholesterol ____________________ Infections ____________________ Infertility ____________________ Insomnia ____________________ Irritable bowel ____________________ Learning difficulty ____________________ Lupus ____________________ Migraines ____________________ Multiple sclerosis ____________________ Miscarriage ____________________ Obesity ____________________ Osteoarthritis ____________________ Osteoporosis ____________________ Overactive thyroid ____________________ Overweight ____________________ Parkinson’s disease ____________________ Polycystic ovaries ____________________ Poor stress response ____________________ Prematurity __________________ Raynaud’s disease __________________ Rheumatoid arthritis __________________ Schizophrenia __________________ Sinusitis __________________ Sjrogen’s disease __________________ Underactive thyroid __________________ Underweight Are your parents alive and well? Yes/no Are your grandparents alive and well? Yes/no If either of your parents or grandparents died at a young age then please explain as best you can their cause of death. ___________________________________ ___________________________________ ___________________________________ PLEASE DESCRIBE HOW YOU PERCEIVE THE HEALTH OF YOUR FAMILY ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ PLEASE DESCRIBE ANY MEDICAL TESTS THAT YOU HAVE HAD IN THE PAST AND IF THERE WERE ANY SIGNIFICANT FINDINGS ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Digestion & Elimination C = current RP = recent past P = past _____ Abdominal pain _____ Anal irritation _____ Black stool _____ Bloating _____ Bolt food _____ Bulky stool _____ Constipation _____ Diarrhoea _____ Difficulty chewing _____ Dry mouth _____ Eat on the move _____ Eat when stressed _____ Excess saliva _____ Food poisoning _____ Flatulence _____ Gall stones _____ Haemorrhoids _____ Heartburn _____ Hiatus hernia _____ Incomplete motion _____ Indigestion _____ Irritable bowel syndrome _____ Mucus in stool _____ Morning nausea _____ Nausea _____ Offensive stool _____ Pain under right rib cage _____ Pale stool _____ Parasites _____ Pus in stool _____ Reflux _____ Stools that sink _____ Stools that float _____ Thrush _____ Worms STRESSORS C = current RP = recent P = past _____ Bereavement _____ Changed jobs _____ Dazzled by lights _____ Dizzy sitting to standing _____ Excessive exercise _____ Feel too hot or too cold _____ Financial loss _____ Job promotion _____ Legal problems _____ Marriage _____ Moving home _____ Multi task _____ New parent _____ Overcommitted _____ Palpitations _____ Panic attacks _____ Pain _____ Personal achievement _____ Physical illness _____ Physical injury _____ Redundancy _____ Retirement _____ Separation Inflammation C = current RP = recent past P = past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acne Arthritis Asthma Boils Bronchitis Cancer Conjunctivitis Crohn’s disease Cystitis Dermatitis Diverticulitis Eczema Food allergy Food intolerance Gastritis Gingivitis Hayfever Heart disease Herpes Hepatitis Hives IBS Infections Joint pains Labyrinthitis Mastitis Nephritis Oesophagitis Otitis media Pancreatitis Pelvic inflammation Prostatitis Psoriasis Rhinitis Sinusitis Twisted testicles SLE Ulcers Urethrits _____ _____ _____ _____ Sweat a lot Unclear about goals Unhappy at home Unhappy at work Please explain your main life stressors _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Toxic Load CH/M = current high/moderate RPH/M = recent past high/moderate PH/M = past high/moderate _____ Alcohol _____ Allergies _____ Caffeine _____ Cannabis _____ Copper water pipes _____ Drink tap water _____ Electrical exposure _____ Exercise in polluted areas _____ Exercise levels _____ Exposure to moulds _____ Food additives _____ Food pesticides _____ Food preservatives _____ Home decorating _____ Home gardening _____ In heavy traffic _____ Infections _____ Inflammatory disorders _____ Intake of oily fish _____ Lead water pipes _____ Live in a city area _____ Live in a smoky environment _____ Live near pylons _____ Live on a farm _____ Mercury fillings _____ Play golf _____ Processed foods _____ Unwashed fruit/vegetables _____ Smoker _____ Work with paints/chemicals _____ Work in ‘smoky’ environment Detoxification C = current RP = recent P = past _____ Athletes foot _____ Bad breath _____ Caffeine keeps you awake _____ Cellulite _____ Chronic headaches _____ Coated tongue _____ Constipation _____ Dark under eyes _____ Dark urine _____ Dehydration _____ Feeling of hangover _____ Fluctuating mood _____ Fluctuating weight _____ Itching _____ Lethargy _____ Muscle aches _____ Offensive breath _____ Offensive body odour _____ Offensive urine _____ Premature ageing _____ Regularly dieting _____ Verrucae/warts _____ Water retention _____ Weight gain _____ Worse in damp weather _____ Yellow discolouration skin/eyes ALLERGY C = current RP = recent P = past _____ Anaphylaxis _____ Bed wetting _____ Been tested by doctor _____ Bloat after eating _____ Carry epipen _____ Ever hospitalised _____ Excess mucus _____ Face ache _____ Growing pains _____ Hives _____ Itchy eyes _____ Itchy nose _____ Itchy skin _____ Itchy throat _____ Learning difficulties ______ Migraines _____ Mouth ulcers _____ Rashes _____ Red ears _____ Sneeze a lot _____ Swollen lips _____ Swollen throat _____ Tired after eating _____ Worse after eating List foods and/or chemicals that you react to: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ STRESS RESPONSE Consider your response to stress. Do not compare yourself with others. Only consider how you feel in yourself. (please circle) Good OK Poor What measures do you take to manage stress? ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Weight History (please use the space below to describe your weight trends over your lifetime i.e. from birth until now) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Are you happy with your weight? If not, then please explain further ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ HORMONAL HISTORY – WOMEN ONLY Yes = Y No = N _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Any complications in labour? Any complications in pregnancy? Any facilitated conception/s? Any history of endometriosis? Any history of fibroids? Anyhistoryofhighthyroidfunction? Any history of hormone cancer? Any history of miscarriage? Anyhistoryoflowthyroidfunction? Anyhistoryofpolycysticovaries? Any indication of osteoporosis? Any premature births? Any problems breast-feeding? Any problems conceiving? Are you currently pregnant? Currentlyusethecontraceptivepill? Currently use HRT (synthetic)? Currently use natural hormones Did you breast-feed? Do you / have you an IUD fitted? Have you experienced a stillbirth? Normal deliveries? Planning a pregnancy? Regular well-woman checks? GENERAL SYMPTOMS C = current RP = recent past P = past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Abdominal weight gain Acne Addicted to foods Addicted to stimulants All boy family All girl family Better after exercise Cataracts Carry weight hips and thighs Carry weight back and shoulders Coarse hair Coarse skin Cold extremities Clammy skin Clumsy Crave sweet food Cry easily Difficulty gaining weight Dry skin Excessive body hair Excessive salivation Excessive sweating Faint without regular food Fast metabolism Feel cold Feel hot Food cravings EXERCISE PATTERN _____ _____ _____ _____ _____ Are you very active? Are you moderately active? Are you sedentary? Do you enjoy exercise? Do exercise regularly? Explain the type of exercise, frequency, duration and place of exercise. ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ If you do not take regular exercise, please indicate the factors that prevent you from doing so. ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Fluctuating weight Fractures Glaucoma Good appetite Good teeth Good pain tolerance Hair loss Hair growth High pain threshold High sex drive Kidney stones Little body hair Long fingers and toes Low pain threshold Low sex drive Loss of hair colour Low protein intake Macular degeneration Morning nausea Need to eat regularly Palpitations Pale skin Poor appetite Prone to dental decay Protruding ey Receding gums Reduced sweating Referred itches Sexually transmitted infection Short fingers and toes Swollen neck Tired after eating Weight loss ENERGY, SLEEP & MOOD C = current RP = recent P = past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Addictive Apathetic Asleep after midnight Aggressive Angry Anxious Apathetic Best evenings Best mornings Competitive Creative Cry easily Depression Difficulty getting to sleep Difficulty getting up Difficulty waking up Dream a lot Dull Easily aroused Easily fatigued Easily provoked Easily satisfied Exhaustion Expressive nature Fatigue Feel sleepy during the day Feel tired all the time Fluctuating energy Foggy brain Frustration Gregarious nature Happy Heavy sleeper Hyperactive Hypercritical Insomnia Intuitive Irritability Light sleeper Mood swings Obsessive Often dissatisfied Passive Poor concentration Poor memory Remember dreams Relax easily Sad Self-centred Shift worker Sleep before midnight Sleep less than 7 hours Sleep more than 8 hours Snore Tension Unrefreshed after sleep Up after 9am Wake during night Wake refreshed CIRCULATION C = current RP = recent P = past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Active Anaemia Angina Blood clots Blue extremities Calf pain Chest pain Cold hands/feet Enjoy exercise Groin pain Fatty arteries Hardened arteries High blood pressure High cholesterol High triglycerides Low blood pressure Lung disease Nose bleeds Obesity Pain in legs on walking Red face Sedentary Stroke Thick blood Thin blood Thread veins Varicose veins HORMONAL SYMPTOMS C = current RP = recent past P = past WOMEN _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Breast lumps Heavy periods Hormone cancer Hot flushes Infertility Irregular periods Mastitis Painful intercourse Painful periods PMS Scant periods Vaginal bleeding Vaginal discharge Vaginal dryness _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ Altered urine flow Enlarged prostate Hormone cancer Hypospadias Impotence Infertility Minimal shaving Low sperm count Lowspermmotility Painfulintercourse Prostatitis Swollen testicles Undescended testes MEN ACCIDENTS AND INJURIES Please detail the nature and severity and recovery from any accidents and injuries during your life, with approximate dates. ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ __________________ KEY OBSERVABLE SIGNS & SYMPTOMS OF POTENTIAL NUTRIENT DEFICIENCIES (to be taken into account alongside other factors) C = current RP = recent past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acne Bumps on skin Burning eyes Cataracts Dry eyes Dry hair Dry skin Dull hair Itchy eyes Inflamed eyelids Peeling nails Poor night vision Rigid nails Rough skin Thickened skin Tired eyes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Dermatitis Eczema Grooved tongue Painful gums Red tip of tongue Red tongue Raw tongue Scaly skin Shiny/glossy tongue Smooth tongue Sore mouth Swollen mouth _____ Ulcers _____ Tooth decay _____ _____ _____ Burning feet Eczema Hair loss _____ _____ Painful tongue Teeth grinding _____ _____ _____ _____ _____ _____ _____ _____ _____ Bleeding gums Gingivitis Easy bruising Enlarged veins under tongue Pallor Red pimples on skin Short of breath Slow wound healing Thread veins _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acne Cracks at corners of mouth Dermatitis Eczema Flaky skin Hair loss Oily skin Painful tongue Pallor Shiny/glossy tongue Short of breath _____ Varicose veins _____ _____ _____ Excess wrinkles for age Pallor Shortness of breath _____ Slow wound healing _____ Water retention _____ _____ _____ _____ _____ _____ _____ Bone Pain Fracture risk Frequent stool Frequent sore throat Leg cramps Light sleep Tender muscles _____ _____ _____ _____ _____ _____ _____ _____ Difficulty walking Pallor Raw tongue Red tongue Red tip of tongue Shiny/glossy tongue Short of breath Smooth tongue _____ Unsound sleep _____ Ulcers _____ _____ _____ _____ _____ _____ _____ _____ _____ Cracks at corners of mouth Crusty eyes Dermatitis Hair loss Loss of eyebrows Painful tongue Purplish tongue Scaly skin Shiny/glossy tongue _____ _____ _____ _____ _____ _____ _____ Cracks at corners of mouth Painful tongue Pallor Raw tongue Red tongue Scaling lips Short of breath ____ Smooth tongue _____ Watery eyes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Constipation Dry eyes Dry hair Dry mouth Dry skin Dry vagina Eczema Excess thirst Lifeless hair Rough skin Slow wound healing _____ _____ _____ _____ _____ _____ _____ Easy bruising Eye bleeds Gum bleeding Heavy menstrual bleed Nose bleeds Pallor Prone to fractures _____ Ulcers _____ _____ Dandruff Loose skin _____ Premature ageing A C E D B1 B2 BIO _____ _____ _____ _____ _____ _____ _____ B3 B5 B6 B12 F _____ Shortness of breath K _____ _____ _____ _____ Difficulty hearing Difficulty walking Numbness Premature ageing _____ Sore knees _____ _____ Food cravings Obese _____ Weight gain Mn Cr P = past Brittle nails Dandruff Dry skin Eczema Hair loss Pallor Scaly skin _____ Shiny/glossy tongue EFA _____ _____ _____ _____ _____ Hair breaks easily Poor growth Poor muscle mass Slow wound healing Split nails _____ Water retention _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Constipation Hair loss Inflamed tongue Lustreless hair Pallor Poor exercise tolerance Poor skin tone Shiny/glossy tongue Short of breath Spoon shaped nails P _____ Vertical ridged nails Fe _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Acne Bumps on skin Dandruff Dry skin Hair loss Oily hair Poor appetite Poor night vision Poor smell Poor taste Premature grey hair Slow growth Slow wound healing Short of breath Stretch marks Ulcers _____ White flecks on nails Zn _____ _____ _____ _____ _____ _____ Excess wrinkles for age Lax joints Pallor Reduced skin pigment Shortness of breath Skin sores _____ Weakness _____ _____ _____ _____ _____ _____ Brittle nails Eczema Leg cramps Muscle spasms Poor growth Prone to fractures _____ Tooth decay _____ _____ _____ _____ _____ _____ Constipation Dry hair Dry skin Leathery skin Swollen neck Voice deepened _____ Weight gain AO C/M I Blood Group (if known) A/B/O Neg/Pos Include all meals, snacks and drinks for the 24 hour period of each chosen day. Include a typical Saturday and Sunday as well as two weekdays. Remember to include all drinks, including water, coffee, tea, juice and alcohol. Food Analysis E.g. 8am 2oz (70g) Kellog’s cornflakes; ¼ pint semi-skim milk; 1 teaspoon sugar; 1 mug tea with 1 tablespoon semi-skim (no sugar) 11am 2 plain digestive biscuits and 1 mug of black coffee 1pm: 2 slices of wholegrain bread with scraping of butter and 1 large tomato Day 1 from first to last intake - record all food, drink and timings ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ If you have changed your diet recently then _ please indicate as above a typical prior day on a separate sheet of paper. This will not be analysed but will be taken into account in the commentary. Do you: C _____ _____ _____ _____ _____ _____ _____ = current RP = recent P = past Eat our frequently? Cook for more than one? Enjoy entertaining? Enjoy preparing food? Find shopping easy? Live alone? Purchase much organic food? List your most favourite foods: _____________________________________ _____________________________________ List the foods you dislike: _____________________________________ _____________________________________ List the foods you would find hard to give up: _____________________________________ _____________________________________ Explain any special diet you are following or have followed (including vegan/vegetarian): _____________________________________ _____________________________________ Do you eat to live or live to eat? _____________________________________ _____________________________________ Briefly describe your attitude to food _____________________________________ _____________________________________ Were you breast fed? Yes / No Were you raised on a health diet? Yes / No Day 2 from first to last intake – record all food, drink and timings __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Do you: C = current RP = recent P = past _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Add salt to cooking or food? Add sugar to food or drink? Avoid additives and preservatives? Choose mainly low fat foods? Drink more than two coffee’s daily? Drink more than two teas daily? Drink more than 2 units of alcohol daily? Eat a lot of chocolate? Eat a lot of confectionery? Eat a lot of dairy products? Eat a lot of fried food? (not stir fry) Eat a lot of high fat foods? Eat a lot of ready meals? Eat a lot of refined food? Eat a lot of salty food? Eat a lot of wheat products? Eat 3 + portions of vegetables a day? Eat 2 + portions of fruit a day? Eat oily fish more than twice weekly? Eat red meat more than twice weekly? Frequently use prepared sauces? Mainly cook with vegetable oils? Mainly drink tap water? Mainly eat fresh fruit and vegetables? Mainly use margarine? Regularly cook with polyunsaturated oils? Regularly drink undiluted juice? Regularly eat beans and lentils? Regularly eat cakes and biscuits? Regularly eat take-away meals? Regularly eat nuts and seeds? Regularly eat processed meats? Regularly microwave food? Regularly wash fruit and vegetables? Regularly peel fruit and vegetables? Day 3 from first to last intake - include all food, drink and timings __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Day 4 from first to last intake - include all food, drink and timings __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________