Follow-up Questionnaire

Please enter your patient ID number
Please list the main problems since your last visit
Please list any problems you had coping with your diet and supplements
Please list the supplements you have taken
Please list the main obstacles you see to your getting better
Please list areas you feel have improved and areas you feel that have worsened

Record foods eaten in your last breakfast meal
Record foods eaten in your last lunch meal
Record foods eaten in your last dinner meal
Record snack foods and any drinks (including amount of water) consumed over the last 24hrs
Record any exercise type and duration completed in the last week
Record relaxation activities over the last week

Digestive Power - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Burping or bloating?
Fullness or indigestion after meals?
Undigested food in your stool?
Constipation?
Diarrhoea?
Nausea or vomiting?
Abdominal pain?
Food Reactions - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Reactions to any foods?
Nasal congestion?
Skin rashes, eczema, dermatitis?
Asthma?
Itchy ears?
Throat irritation or coughing?
Hay fever?

B Vitamins - have you suffered with any of the following in the last 30 days?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Burning feet?
Trouble sleeping?
Watery eyes?
Eyes sensitive to light?
Mouth soreness?
Reduced appetite?
Nerves feeling "on edge"?
Tremor when holding objects?
Cracks in the corners of mouth?
Poor dream recall?
Eye irritation?
Pins and needles?
Increased clumsiness?
Increased forgetfulness?

Zinc - have you suffered with any of the following in the last 30 days?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
New white spots on nails?
Recurrent infections?
Slow wound healing?
Increased hair loss?
Bad breath?
Reduced taste or smell sensation?
Trouble adapting to dark rooms?

Magnesium - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Episodes of dizziness?
Tremors?
Muscle or eye twitching?
Muscle cramps?
Palpitations?
Protein - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Irritability?
Poor motivation?
Missed meals?
Vitamin C - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Slow wound healing?
Bleeding gums?
Bumpy skin on arms, legs or buttocks?
Easy bruising?
Achy legs?
Vitamin A - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Recurrent infections?
Dry, itchy eyes?
Poor night vision?
Dry mouth?
Essential fatty acids - have you suffered with any of the following in the last 30 days?
Never Occasionally/Mild Often/Moderate Always/Severe
Excess ear wax?
Dry brittle hair?
Dandruff?
Brittle nails?
Dry skin?
Dry, cracked heals?
Pain - thinking about the last 30 days
Never Occasionally/Mild Often/Moderate Always/Severe
How often have you had pain?
How often has pain affected your activities?
How often has pain affected your sleep?
Energy - thinking about the last 30 days
Never Occasionally/Mild Often/Moderate Always/Severe
Do you wake tired in the morning?
Are you sleepy during the day?
Do you recover poorly from exertion?
Brain function - thinking about the last 30 days, have you suffered
Never Occasionally/Mild Often/Moderate Always/Severe
Poor concentration?
Short-term memory loss?
Depression or feeling down?
Mind fogginess?

Liver function - thinking about the last 30 days, have you experienced

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Chemical reactions?
Poor alcohol tolerance?
Pesticide exposure?
Regular prescribed or unprescribed drug use?
Smoke exposure (personal or passive)?
Unexplained itching, esp at night?

Blood sugar - thinking about the last 30 days, have you experienced
Never Occasionally/Mild Often/Moderate Always/Severe
Fatigue after meal?
Snoring?
Shaky, jittery or tremors if meals are delayed?
Sweet cravings?
Anxiety associated with hunger?

Adrenal function - thinking about the last 30 days, have you experienced

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Poor exercise tolerance?
Dark circles under the eyes?
Light headedness on standing?
Fatigue 1-2 hours after eating?
Sock mark on your ankle?
Regularly feeling stressed?

Sleep - in the last week
<5 6 7 >8
Average hours of sleep per night
Meditation - in the last week
Daily Less than daily Never
Meditation sessions
Other information

Please include any other relevant information such as investigations ordered by other practitioners, new medications or supplements started etc

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Burping or bloating?
Fullness or indigestion after meals?
Undigested food in your stool?
Constipation?
Diarrhoea?
Nausea or vomiting?
Abdominal pain?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Reactions to any foods?
Nasal congestion?
Skin rashes, eczema, dermatitis?
Asthma?
Itchy ears?
Throat irritation or coughing?
Hay fever?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Episodes of dizziness?
Tremors?
Muscle or eye twitching?
Muscle cramps?
Palpitations?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Slow wound healing?
Bleeding gums?
Bumpy skin on arms, legs or buttocks?
Easy bruising?
Achy legs?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Recurrent infections?
Dry, itchy eyes?
Poor night vision?
Dry mouth?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Excess ear wax?
Dry brittle hair?
Dandruff?
Brittle nails?
Dry skin?
Dry, cracked heals?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
How often have you had pain?
How often has pain affected your activities?
How often has pain affected your sleep?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Do you wake tired in the morning?
Are you sleepy during the day?
Do you recover poorly from exertion?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Poor concentration?
Short-term memory loss?
Depression or feeling down?
Mind fogginess?

	Never	Occasionally/Mild	Often/Moderate	Always/Severe
Fatigue after meal?
Snoring?
Shaky, jittery or tremors if meals are delayed?
Sweet cravings?
Anxiety associated with hunger?

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