The Endometriosis and Fertility Clinic Questionnaire
Please complete this document as best as you can and when you click the submit button this will email your questionnaire to The Endometriosis and Fertility Clinic, thank you.
It may be easiest to print this out and fill in with a pen before completing online, as it is a large and complex questionnaire
Private and Confidential
This document is Private and Confidential and the information provided is for the inclusive use of The Endometriosis and Fertility Clinic, Our commitment to you is to provide the most appropriate treatment for your needs. This questionnaire is designed to provide your nutritionist with all the information necessary to build you an individual nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.
First Name: Last Name: Your sex M/F Address: City: County: Country : Post Code: eMail: Telephone Number:(Work) (Home) (Mobile) Occupation: Date of Birth: What is your Weight (without clothes): Stone lbs or kg Has your weight changed recently? What is your Height (without shoes): Feet inches or cm
If you have had other clinical test, then please bring relevant copies of those results with you to the clinic How did you hear about The Endometriosis and Fertility Clinic? What other Complementary Therapies have you tried? Which therapies did you find most helpful? Doctor’s Name: Address: Tel: Consultant’s Name: Address: Tel: Do you give permission for your medical Doctor to be contacted? Number of Doctors seen Number of Consultants seen
Please make a list of all the health problems you would like to clear up, and indicate how long you have had these problems eg: Headaches 5 years (Continue on a separate sheet if you need more space)
Health problem 1 Duration: GP consulted 2 Duration: GP consulted 3 Duration: GP consulted 4 Duration: GP consulted 5 Duration: GP consulted 6 Duration: GP consulted
What medications (drugs) do you take for these? State daily dose Under what circumstances do these problems improve? Under what circumstances do they get worse? What other illness have you had in the past ten years? What operations have you had? What is your normal blood pressure? (don't worry if you don't know) What is your resting pulse rate per minute? (You should be sitting down, relaxed and calm when you take your pulse. Your pulse can be found inside the boney protuberance on the thumb side of your wrist. Count the number of beats in 60 seconds.)
Heredity Profile Do you have any children? If so, state age and sex. SexAgeillnesses suffered M/F M/F M/F How many brothers and sisters do you have? State sex, age and illnesses suffered. SexAgeillnesses suffered M/F M/F M/F Does anyone in your family have the following? (tick those that apply) Asthma Eczema Hayfever Arthritis Diabetes Coeliac Disease Thyoid problems Irritable Bowel Problems Migraines Cancer Osteoporosis Any Allergies What illness is/was your father prone to? What illness is/was your paternal grandfather prone to? What illness is/was your paternal grandmother prone to? What illness is/was your mother prone to? What illness is/was your maternal grandfather prone to? What illness is/was your maternal grandmother prone to?
Heredity Profile
Does anyone in your family have the following? (tick those that apply)
Symptom Analysis
Each question in this section starts with a list of symptoms associated with nutritional deficiency. Tick the box by the conditions you often suffer from. Some symptoms are repeated. Please tick them in all cases.
Cardiovascular Profile
Is your blood pressure above 140/90? Is your pulse after 15 minutes rest above 75? Are you more than 14lbs (7kg) over your ideal weight? Do you smoke more than 5 cigarettes a day? Do you do less than two hours exercise a week? Do you have a pain in your calves on walking? Do you eat more than one spoon of sugar a day? Do you usually add salt to your food? Do you have more than 2 alcoholic drinks a day? Is there a history of heart disease in your family? Do you have tightness/chest pains? Do you have high cholesterol? Do you have high homocysteine? Do you have swollen ankles?
Exercise Profile
Do you take exercise that noticeably raises your heart beat for 20 minutes more than 3 times a week? Does taking exercise cause pain/exhaustion? Does your job involve vigorous activity? Do yo regularly play sport? (football, squash, etc) Do you have any physically tiring hobbies? (gardening, yoga, aerobics, etc) Do you consider yourself fit?
Pollution Risk Profile
Do you live in a city or by a busy road? Do you spend more than 2 hours a week in traffic? Do you exercise (job, cycle, play sports) by a busy road? Do you smoke more than 5 cigarettes a day? Do you live or work in a smoky atmosphere? Do you buy foods exposed to exhaust fumes? Do you generally eat non-organic produce? Do you drink more than 1 unit or oz of alcohol a day? (1 glass of wine, 1 pint of beer, or 1 measure of spirits) Do you spend a lot of time in front of a TV or VDU? Do you usually drink unfiltered tap water? Do you have mercury fillings in your teeth?
Stress Profile
Do you have low self esteem? Does stress make you feel exhausted? Is your energy less now than it used to be? Do you feel guilty when relaxing? Do you have a persistent need for achievement? Are you unclear about your goals in life? Are you especially competitive? Do you work harder than most people? Do you easily become angry? Do you often do 2 or 3 tasks simultaneously? Do you get impatient if people or things hold you up? Do you have difficulty getting to sleep? Do you wake to early? Have you had a personal loss/trauma in the past year?
Respiratory Profile
Do you cough at night? Do you suffer shortness of breath with exercise? Do you have recurrent chest infections or sinus problems? Do you work in a smoky environment? Do you wheeze?
Glucose Tolerance Profile
Do you crave particular foods? (Name them) Do you need more than 8 hours sleep a night? Are you rarely wide awake within 20 minutes of rising? Do you need something to get you going in the morning, like a tea, coffee or cigarette? Do you have tea, coffee, sugar containing foods or drinks, or cigarettes at regular intervals during the day? Do you often feel drowsy during the day? Do you get dizzy or irritable if you don't eat often? Do you avoid exercise due to tiredness? Do you sweat a lot or get excessively thirsty? Do you sometimes lose concentration? Is your energy less now than it used to be?
Muscular/Skeletal Profile
Do you have lower back pain? Do you have joint pain/stiffness? Do you have osteoporosis? Have you had bone fractures?
Digestion Profile
Do you chew your food thoroughly? Do you sometimes suffer from bad breath? Are you prone to stomach upsets? Are you prone to piles? Do you often get a burning sensation in your stomach? Do you find it difficult digesting fatty foods? Do you occasionally use indigestion tablets? Which foods give you indigestion? Do you suffer from flatulence or bloating? Do you experience anal irritation? Do you have a bowel movement daily? Do your stools float? Do your stools contain blood mucus appear yellow & oily Do you regularly suffer from Diarrhoea? Is this linked with menstruation? Do you regularly suffer from constipation? Is this linked with menstruation?
Pain Profile
Is your pain: (tick which applies) sharp stabbing lacerating cutting skewering hot burning intense overwhelming wringing twisting taut yanking deep aches mild cramps killer cramps excruciating breath taking can't move just discomfort mild twinges
Immune Profile
Do you get more than three colds a year? Do you find it hard to shift an infection (cold or otherwise)? Are you prone to thrush or cystitus? Do you often take antibiotics more than twice a year? Is there a history of cancer in your family? Have you ever had any growths or lumps biopsied? Do you have an inflammatory disease such as eczema, asthma or arthritis? Do you suffer from hayfever? Do you suffer from allergy problems? Have you had a major personal loss in the last year?
Nervous System Profile
Do you have fainting episodes? Do you go dizzy or loose your sense of balance? Do you have a ringing in your ears? Have you ever had any seizure or epilepsy? Are you prone to depression/despair/low mood swings? Do you have any obsessions or feel overly suspicious? Do you have poor concentration or short memory? Do you have hot feet, cracked heels, teeth grinding?
Skin Profile
Do you have dry skin? Do you have acne? Do you have eczema? Do you have psoriasis? Do you have flaky skin? Do you have greasy skin? Do you have dermatitis? Do you have boils? Do you have cysts? Do you have warts? Do you have a verruca?
Weight Profile
Do you have an inability to gain weight? Do you have an inability to lose weight? Is your weight static? Is your weight gain central back hips/thighs? Do you have unexplained weight loss? Do you have unexplained weight gain?
Histamine Profile
tick the following that apply to you:
Allergy Profile
Do you suffer from any of the following? Please tick Nasal problems hay fever eczema dermatitis asthma migraine irritable bowel syndrome frequent bloatedness facial puffiness. Do you have any allergies? If so what? Food: Chemicals: State type of reaction. Have they been tested. What foods or drinks would you find hard to give up?
Additional Questions for Women Only
Are you pregnant? if so how many weeks? Are you trying to become pregnant? Have you ever had a miscarriage? Do you have an IUD fitted, or use the birth control pill? State which Are your periods regular? Are you post-menopausal? Do you suffer from any of the following, tick those that apply: pre-menstrual bloatedness tiredness irritability depression breast tenderness headaches
Diet Analysis
Please tick the questions to which you would answer 'yes' or fill in the 'number of times' you eat the food referred to in the question.
Were you breast feed? Was a significant percentage of your diet as a child high in fatty foods and sugar? Do you go out of your way to avoid foods containing preservatives or additives? Do you avoid foods which contain sugar? How many teaspoons of sugar do you add to food/drinks each day? Do you use salt in your cooking? Do you add salt to your food? How many coffees do you drink each day? How many cups of tea do you drink each day? How many times a week do you have meals containing fried food? How many packets of 'instant' or fast foods do you eat each week? How many times a week do you eat chocolate or confectionary? What percentage of your diet is raw fruit and raw vegetables? Do you wash fruit and vegetables before eating? Do you normally eat white rice or flour? How many cans of food do you eat per week? How many slices of bread or rolls do you eat each week? How many pints of milk do you drink in a week? How many times a week do you eat red meat? (beef, pork, lamb or game) How many times a week do you eat white meat? (poultry, fish) What is your usual alcoholic drink? How many glasses do you drink a week? How many times a week do you eat live yoghurt? Do you use a water filter or drink bottled water instead of tap water? Do you frequently eat under stressful conditions or on the move? Does your job involve eating out a lot? How would you describe your appetite?poor averagegood
Sample Diet
Write down all the foods and drinks consumed over the next two days, starting today. Please add as much information as possible including quantities eaten brand names, and whether the food is fresh or packaged, refined or natural.
Day 1
Breakfast
Lunch
Dinner
Snacks/Drinks
Day 2
Are these two days representative of your usual eating habits? If not, what is a more usual day?
What Nutritional Supplements do you take daily on a regular basis?
Evening
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