The Wellness Junction Nutrition and Health Assessment Questionnaire - Inner Harmony with Stiana

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The Wellness Junction Nutrition and Health Assessment QuestionnaireStiana Hubert2025-02-01T08:48:27+00:00

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Take your time to answer all the questions as fully and accurately as possible, as this information will enable us to create a protocol specifically tailored to your needs. Please don’t be put off by the length of the questionnaire.
Name
First Middle Last
Date of Birth

Day
Month
Year
Age
Gender
- Female
- Male
Address
Street Address Address Line 2 City County Post Code Country
Email
Home Phone
Mobile Phone
How would you rather be contacted?
- Home Phone
- Mobile Phone
- Email

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Your Weight
Your Height
Do you have a record of your blood pressure?
- Yes
- No
Blood Pressure
Date Last Blood Test Taken
DD slash MM slash YYYY
General Practitioner’s Details
Doctor’s Name
Phone
Do I have permission to contact your GP if it is necessary to do so?
- Yes
- No
Address
Street Address Address Line 2 City County Post Code Country
Family
Do you have children?
- Yes
- No
Please state the age and gender
Occupation
What work do you do?
How many hours do you work on average a week?
Do you work night-shifts?
- Yes
- No
Do you enjoy your work?
- Yes
- No
Do you have exposure to chemicals at work?
- Yes
- No

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Health, Lifestyle and Exercise
Please give details of why you have chosen to make the appointment, giving as much information as possible. State your health concern(s) in the order of priority and including when and how your concern(s) started, how often these symptoms occur, how long you have had the concern and what alleviates or exasperates them. When referring to pain, please specify the type of pain, i.e., whether it is sharp, an ache, dull, whether it comes and goes or whether it is chronic. Please list any previous treatment(s), the duration of the treatment(s) and whether they improved the symptom(s).
Have you ever smoked?
- Yes
- No
How long for?
Do you still smoke?
- Yes
- No
How many cigarettes do you smoke each day?
Do you drink alcohol?
- Yes
- No
How many days a week on average do you drink alcohol, how much do you drink each day and what is your preferred drink?
Do you/have you ever taken recreational drugs?
- Yes
- No
Which drugs have you taken & when was the last time you took these drugs?
Do you exercise?
- Yes
- No
How many times each week?
On average how long do you exercise for?
What type of exercise do you do?
Where do you exercise?
How would you describe your current lifestyle?
- Stressed
- Happy
- Unhappy
- Busy
- Relaxed
Daily Stressors
Please rate your daily stressors on a scale of 1 to 10 (1= Low; 10 = High)
Work
Please enter a number from 0 to 10.
Family
Please enter a number from 0 to 10.
Social
Please enter a number from 0 to 10.
Finances
Please enter a number from 0 to 10.
Health
Please enter a number from 0 to 10.
Do you feel you can easily handle stress in your life?
- Yes
- No
Do you practice any of the following?
- Yoga
- Meditation
- Breathing Techniques
- Prayer
- Other
What are your hobbies?
What is the average number of hours you sleep each night?
- 6 or less
- 6 - 8
- 8 - 9
- 9 - 10
- 10+
Do you have trouble falling asleep?
- Yes
- No
Do you feel refreshed upon waking?
- Yes
- No
Do you wake during the night?
- Yes
- No
Do you dream?
- Yes
- No

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Family History
Please list any blood relatives affected by:
Allergies
Arthritis
Asthma
Cancer
Diabetes
Epilepsy
Heart Disease
High BP
Kidney Disease
Osteoporosis
Mental Illness
Stroke
Tuberculosis
Other
Medical History
Immunisations
- Diphtheria, Pertussis (DPT)
- Mumps
- Measles
- Rubella
- Hepatitis A
- Hepatitis B
- Influenza
- Tuberculosis
- Human Papillomavirus
- Meningitis
- Polio
- Glandular Fever
- Pneumococcal Conjugate Vaccine (PCV) Tetanus
Childhood Illnesses / Diseases
- Chicken Pox
- Croup
- German Measles
- Measles
- Meningitis
- Scarlet Fever
- Tonsilitis
- Whooping Cough
Accidents / Operations
- Head Injury
- Back Injury
- Broken Bones
- Neck Injury
- Appendectomy
- Hernia
- Hysterectomy
- Tonsillectomy
- Gall Bladder
Allergies
- Dairy
- Soy
- Wheat
- Yeast
- Gluten
- Lactose
- Artificial flavourings/colourings
- Metal Jewellery
- Plasters
- Latex
- Rubber
- Dust Mites
- Grass
- Pollen
- Fur
- Food
- Medicines
Do you suffer from any major/re-current illnesses (e.g. hepatitis, jaundice, diabetes, TB, glandular fever, asthma, herpes or shingles)? Please give details where appropriate.
Recent test results (within the last 12 months) - please forward copies of the results with your assessment form).
Do you currently take any prescription medication?
- Yes
- No
Do you currently take any prescription medication, if so please list them below and please specify whether you experience any side effects.
Do you currently take any nutritional supplements? If so please list them in the table below and please state whether you experience any side effects.
Other Medical Information
Were you born naturally?
- Yes
- No
Were you breast fed (If known)?
- Yes
- No
How many courses of antibiotics have you had throughout your life?
When was the last time you had antibiotics?
DD slash MM slash YYYY
Do you suffer any headaches/migraine?
- Yes
- No
How often do they occur?
Do you get any visual disturbances?
- Yes
- No
Are there specific things that triggers them?
What are they and how often do they occur?
Do you experience blurred vision?
- Yes
- No
How often does this occur
Do you suffer with photophobia?
- Yes
- No
State frequency and possible trigger
Do you suffer from dizziness?
- Yes
- No
How often does this occur?
Do you bump into things, trip, stumble or feel clumsy?
- Yes
- No
Do you suffer from weakness?
- Yes
- No
Do you have aching muscles, but not due to exercise?
- Yes
- No
Do you crave salty foods?
- Yes
- No
Do you find that you get tired or exhaust easily?
- Yes
- No
Do you experience pins and needles?
- Yes
- No
State the location(s) and frequency
Do you experience numbness, tingling and prickling sensation in hands and feet?
- Yes
- No
Please provide details
Do you experience muscle cramps or spasms?
- Yes
- No
Do you get an irresistible urge to move your legs?
- Yes
- No
Do you have bouts of nausea without vomiting?
- Yes
- No
Do you have body parts that are tender, sore, sensitive to touch?
- Yes
- No
Does your heart beating too quickly, too slowly or irregularly?
- Yes
- No
Please provide details
Do you have cold feet for no apparent reason?
- Yes
- No
Do you suffer from sore throats?
- Yes
- No
How often?
Do you have trouble thinking or concentrating?
- Yes
- No
Do you tend to forget things?
- Yes
- No
Do you have difficulty absorbing new information?
- Yes
- No
Do you suffer any fainting or fits?
- Yes
- No
Do you suffer any flatulence?
- Yes
- No
Do you experience any flatulence minutes after eating?
- Yes
- No
Do you suffer any bloating and a sense of abdominal fullness?
- Yes
- No
Do you suffer any burping?
- Yes
- No
Do you suffer any reflux?
- Yes
- No
Do you suffer any vomiting?
- Yes
- No
Do you experience any pain in your abdomen?
- Yes
- No
Please state location, i.e. lower left/right
How many times a day do you produce a stool?
Do you experience any pain when passing a stool?
- Yes
- No
Is your stool odor embarrassing?
- Yes
- No
Does your stool colour alternate from clay colour to normal?
- Yes
- No
Have you noticed any blood in your stool?
- Yes
- No
Does your stool(s) float?
- Yes
- No
Are you generally constipated, or straining during bowel movements?
Do you fluctuate between being constipated and having diarrhoea?
- Yes
- No
Do you pass any mucus with your stool?
- Yes
- No
Do you suffer from haemorrhoids?
- Yes
- No
Do you experience any rectal itching or cramping?
- Yes
- No
Do you feel experience abdominal discomfort or nausea after eating fatty foods?
- Yes
- No
Have you had any weight change recently?
- Yes
- No
Please provide details
How many colds do you typically get in a year?
Does your cold symptoms last longer than five days?
- Yes
- No
Do infections settle in your lungs?
- Yes
- No
Do you cough up lots of phlegm?
- Yes
- No
Do you suffer from wheezing or difficulty in breathing?
- Yes
- No
Do you suffer with ear ache or ear infections?
- Yes
- No
Does your ears, nose, throat and lung symptoms seem to be associated with specific foods, like dairy or wheat?
- Yes
- No
Which foods?
Do you have any varicose veins?
- Yes
- No
How would you describe your skin?
- Oily
- Dry
- Acne
Do you suffer with eczema?
- Yes
- No
Please state the location(s)
Do you suffer with psoriasis?
- Yes
- No
Please state the location(s)
Do you suffer with any rashes?
- Yes
- No
Do you suffer with athlete’s foot?
- Yes
- No
Do you suffer with fungal nails?
- Yes
- No
Do you suffer from thrush?
- Yes
- No
How often does it recur?
Do your wounds heal easily?
- Yes
- No
Do you have an aversion to cold?
- Yes
- No
Do you have an aversion to heat?
- Yes
- No
Do you have cold hands, feet or nose?
- Yes
- No
Do you suffer with loss of body hair growth?
- Yes
- No
Is your outer third of your eyebrows thinning or disappearing?
- Yes
- No
Are you gaining weight for no apparent reason?
- Yes
- No
How many times a day do you urinate?
Do you experience any burning or pain on urination?
- Yes
- No
Do you have any difficulties to start urination?
- Yes
- No
Do you rarely feel the urge to urinate?
- Yes
- No
Do you experience urgency to urinate?
- Yes
- No
Do you have strong smelling urine?
- Yes
- No
Do you have a sense of water retention throughout the body?
- Yes
- No
Do you experience excessive thirst?
Have you had any root canal fillings?
- Yes
- No
Do you currently have silver mercury fillings?
- Yes
- No
Please state how many
Have you been exposed to any of the following over the last 6 months?
Chemicals/Solvents
- Yes
- No
Pesticides/Insecticides
- Yes
- No
Herbicides
- Yes
- No
Heavy Metals
- Yes
- No
Mould
- Yes
- No
Electromagnetic Radiation
- Yes
- No

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Gynaecological History (please write the appropriate number in each box)
Pregnancies
Living Children
Age at first period
Endometriosis
Normal delivery
Baby over 4.5kg (8 pounds)
Length of period
Cesarean Section
Breast Feeding (how long)
Days since menstrual cycle
Miscarriages
Abortion
Have you ever had Gestational Diabetes?
- Yes
- No
Have you ever taken the pill?
- Yes
- No
Hypothyroidism
- Yes
- No
IUD (Inter Uterine Device
- Yes
- No
Post Natal Depression
- Yes
- No
Infertility
- Yes
- No
Fibrocystic Breasts
- Yes
- No
Fibroids
- Yes
- No
PMT
- Yes
- No
Painful periods
- Yes
- No
Heavy periods
- Yes
- No
Breast Biopsy
- Yes
- No
Mammogram
- Yes
- No
Bone Density Test
- Yes
- No
Date
Month
Day
Year
Are you in Menopause?
- Yes
- No
Do you have Hot Flushes?
- Yes
- No
Do you have Vaginal Dryness?
- Yes
- No
Do you have Decreased Libido?
- Yes
- No
Do you have Weight Gain?
- Yes
- No
Do you have Loss of Control of Urine?
- Yes
- No
Do you have Joint Pains?
- Yes
- No
Do you use Hormone Replacement Therapy?
- Yes
- No
Are you affected by:
Change in Libido
- Yes
- No
Impotence
- Yes
- No
Difficulty in obtaining an erection
- Yes
- No
Difficulty maintaining an erection
- Yes
- No
Urge to urinate several times during the night
- Yes
- No
Urgency/Hesitancy/Change in Urinary System
- Yes
- No
Loss of Control of Urine
- Yes
- No
Need to push or strain to begin urination
- Yes
- No
Dripping after urination
- Yes
- No
Prostate Specific Antigen Test (PSA)
- Yes
- No
Please state PSA Level
Rate your levels 1 - 10 (1=low, 10=high)
Rate your energy levels
Please enter a number from 0 to 10.
Rate your stress levels at work
Please enter a number from 0 to 10.
Rate your stress levels at home
Please enter a number from 0 to 10.
Rate your memory
Please enter a number from 0 to 10.
Rate your concentration
Please enter a number from 0 to 10.
Rate your general mood
Please enter a number from 0 to 10.
Rate your general well-being
Please enter a number from 0 to 10.

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Nutrition
Have you ever seen a Nutritional Therapist?
- Yes
- No
Do you currently follow a specific diet, such as Low Fat, Paleo, Vegan, Wheat Free, Dairy Free, 5:2
- Yes
- No
Please specify which and how long you have been on eating in accordance with this?
Have you made any changes to your eating habits due to health?
- Yes
- No
Please specify
Do you struggle with your weight?
- Yes
- No
Which weight loss plans/programmes have you tried and were any effective?
How often do you weigh yourself?
How would you rate your appetite?
Please enter a number from 0 to 10.
(1 = low/10 = high)
Do you enjoy food?
- Yes
- No
Do you avoid any particular foods?
- Yes
- No
Please specify and state the reason why
Do you have any specific cravings for foods?
- Yes
- No
Please state which foods
What are your favourite foods?
Who does the cooking at home?
Who does the food shopping?
Where do you buy the majority of your food?
How many times a week do you dine out?
What sort of food do you eat if you dine out?
What foods and drinks would be hardest to cut out?
How many cups of tea and coffee do you drink a day?
Do you add sugar to your drinks?
- Yes
- No
How many teaspoons?
How many glasses or volume of water do your drink each day?
Do you normally eat white bread, pasta and rice?
- Yes
- No
Do you normally eat brown bread, pasta and rice?
- Yes
- No
Do you eat/drink/use:
Candy/sweets
- Yes
- No
Refined sugar
- Yes
- No
Fizzy drinks
- Yes
- No
Fast-food restaurants
- Yes
- No
Distilled water
- Yes
- No
Fried foods
- Yes
- No
Filtered water
- Yes
- No
Deli meats
- Yes
- No
Margarine
- Yes
- No
Cordials
- Yes
- No
Artificial Sweeteners
- Yes
- No

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Please provide any additional information that you feel may be useful during our consultation
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Please provide any blood test, test results or any other medical information that may be useful for your consultation.
Please state how you heard about my practice?
Data Protection
Information provided for the purpose of the nutrition consultation will be stored in line with legal requirements, seven years for adults and seven years after a child's 18th birthday. All information will be stored in locked storage and on the TWJ database. Each client has the right to request for information held on the TWJ database to be removed.
I consent to my information being stored
- Yes
- No
As part of your healthcare:
TWJ may share your sensitive information with third parties to support your ongoing healthcare. If we do not receive this consent from you, we will not be able to coordinate your healthcare with that provided by other providers which means the healthcare provided by us may be less effective.
Please tick the appropriate boxes to confirm your consent:
- I consent to my sensitive information being shared with other healthcare providers, whose details I have provided
- I consent to my sensitive information being shared with my GP if appropriate
Marketing and Information
TWJ would like to contact you occasionally by email with promotional offers, information on upcoming events, activities and newsletters.
Please tick the appropriate boxes to confirm your consent to be contacted for these purposes:
- I would like to receive regular newsletters
- I would like to receive promotional offers and information on upcoming events and activities
Case Histories
TWJ seeks to continuously improve our practice through professional development, a key part of which is sharing case histories with our peers through clinical supervision, online forums and discussion groups. Your name, address and contact details will never be shared, only information about your health profile.
If you are happy for us to use your data for this purpose, please tick the box below to confirm your consent:
- I consent to my data being used for the purpose of professional development
TWJ would like to share your case history with peers for educational purposes. This could be through conferences, lectures, online forums, and publishing in medical journals, trade magazines or online professional sites. Your name, address and contact details will never be shared.
I consent to my data being used for educational purposes. Please tick the appropriate boxes to confirm your consent:
- Select All
- Conferences
- Lectures
- Online forums
- Trade magazines
- Online professional sites
- Books
You can withdraw your consent to the above at any time by emailing: stiana@innerharmonywithstiana.com
I declare that the information provided is correct and to the best of my knowledge. Please state your name and today's date:
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Date
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