Stress

Welcome to your
OPTIMAL PERSONAL HEALTH QUESTIONNAIRE

THIS QUESTIONAIRE HAS BEEN DESIGNED BY MEDICALLY QUALIFIED INDIVIDUALS TO HELP ESTABLISH SOME OF YOUR STRENGTHS AND WEAKNESSES. IT IS STRUCTURED AS A LIFESTYLE INVENTORY, A MEDICAL QUESTIONAIRE & A SYMPTOM LIST. IT IS DIGITALLY ANALYSED AND WILL ASSIST IN OUR INITIAL ASSESSMENT OF YOUR CURRENT LIFESTYLE AND SUBSEQUENT RECOMMENDATIONS. AS YOU MOVE TOWARDS OPTIMAL HEALTH.

Because of the changes in the food chain, modern farming methods, soil depletion through over-use, insecticides, fertilizers ,fungicides, chemical waste and many other factors we believe most people need to supplement , guard against free radicals and convert to organic eating.

Remember organic doesn’t automatically mean nutritious. It just means free of contaminants. Only mineral-laden,living soil and processing by plants can provide nutrition structured in the molecular form which our bodies can recognise. To protect our bodies the soil also needs to be organic.

The computer collates your information and structures recommendations according to all your answers on the basis of the average person .Each answer is evaluated in relation to an extensive number of nutritional criteria , and the best possible conclusions are drawn.

We believe this assessment to be, in itself, a valuable guide to your requirements.
It should ,however, be remembered that nutritional needs vary widely; and detailed ,face to face, personalized assessments offer a further advantage to those seeking total lifestyle optimal health and fitness. Personal detailed assessments almost always result in very beneficial dietary and lifestyle changes.Supplementation according to this computer assessment is, however, a good start. and we will be pleased to recommend the very few supplement ranges which we consider to be the best and to explain why. Formulae, structure, and production methods for commercial supplements vary widely in terms of effectiveness.
Computer or subsequent consultant recommendations and dietary advice relate to the dietary and lifestyle aspects of disease and disease avoidance only. Frequently this may be all that is necessary.It may also be useful as an adjunct treatment for medical conditions.

N.B. Our advice is followed at the client’s sole discretion and responsibility for following such advice is totally that of the client. The processing of this form and communication of the results is undertaken subject to this absolute condition . Your signature at the top of the page confirms your acceptance of these conditions.

The advice of a specialist medical practitioner should be sought in the case of serious health or disease problems.

The advice of a specialist medical practitioner should be sought in the case of serious health or disease problems.

Title:	Gender: Male Female
First Name: Middle: Surname:
Resting Pulse Rate bpm	Height (approximate) in cm	Weight (approximate) in kgs
Blood Pressure	Date of Birth: dd/mm/year
E-mail address:
Results delivery option (if different from your e-mail address):

Please select the following as appropriate to your living and work situations.
Home Environment	Work Environment		Personal Stress Level
Rural	Rural		None
Suburban	Suburban		Mild
Commercial Area	Commercial Area		Moderate
Industrial Area	Industrial Area		High

Please select as appropriate
Air conditioning at work	Daily exposure to traffic fumes		Organic chemicals on work premises

Estimate or record the number of MEALS PER WEEK in which you have a SERVING of the following . N.B Where foods fall into more than one category record in each category. The more accurate you are the better the analysis.
Foods (servings per week)
Refined complex carbohydrates (such as packaged cereals, white bread, non-whole wheat brown bread, white rice, white pasta
Unrefined complex carbohydrates (such as natural and wholegrain cereals, whole grain bread (not just brown) brown rice, whole sweetcorn or maize, potatoes with skins, yams, unprocessed peas beans lentils, millet etc)
Green Leafy Fresh Vegetables
Red or yellow fresh vegetables
Other fresh vegetables
Fresh non-citrus fruit
Fresh citrus fruit
Simple Sugar foods (Sweetened packaged cereals desserts , cakes, biscuits , custard, tinned fruit commercially prepared pancakes ,waffles, crumpets etc).
Red meat
White Meat ,Poultry Fish, Shellfish Eggs
Any fried meal or fried meal content
Fast food /take-away meals of any type
Packaged chip type snacks
Any milk product- cheese, ice cream cream yogurt etc
Beverages (Number of units : cups ,mugs, glasses,tots per week. The more accurate you are , the better the analysis).
Coffee or standard tea		Decaffinated coffee or tea
Soft drink (non-diet) e.g. Coca cola		Milk, dairy drinks
Diet soft drinks		Alcoholic drinks
Other sweetenned drinks, fruit juices (from concentrate) etc
Sweeteners (Spoonfuls per week)		Condiments & Spreads (helpings per week)
White sugar, syrup		Margarine
Honey, Brown Sugar, Molasses		Jams /Marmalade helpings per week
Atrificial sweeteners, units per week		Prepared Sauces e.g: tomato, mayonnaise, steak
		Butter (units per week - slice of bread equivalent)
		Shakings of Salt per week
Exercise
CARDIOVASCULAR (aerobic) Daily exercise Score according to effort and duration . Use Score of 3 for 20 minutes continuous running at about 10 km/hr as base (equivalent to 1 ½ hours continuous brisk walk ) This would be fairly strenuous . 2 moderate . No exercise 0.				Tick 1, 2 or 3 1 2 3
STRENGTH training or work related exercise (anaerobic ) Circle 1 or2 or 3 Mild lifting or carrying Heavy lifting or carrying at work or light gym training/ circuit Strenuous work lifting regularly or Heavy weight training in gym				Tick 1, 2 or 3 1 2 3
Smoking
Number of cigarettes, cigars , pipes per week
Passive smoking, number of times you are close to someone smoking per week
Regular Medications (please tick which apply to you)
None		Contraceptives
Antacids		Cortisone
Antibiotics		Diuretics
Anti coagulants		Furesimide
Anti convulsives		Indomethacin
Anti diabetics		Kaolin
Anti hypertensives		Levodopa
Anti inflammatories		Penicilin
Aspirin		Phenition
Caffeine containing drugs		Sulphonamide
Cathartics		Trimethoprim
Cimetidine		Tranquilisers
FAMILY HISTORY Please note any family history by noting total numbers of Grandparents, Parents, Brothers or Sisters who have or have had any of the following :
None of the problems listed		Cancer
Osteoporosis		Stroke
Heart disease or attack		Diabetes
Alzheimer's or senile dementia		Arthritis
Breast Problems or cancer		Cataracts
Kidney Stones
CURRENT SPECIFIC SYMPTOM LIST Choose the closest description of your symptoms and circle relevant numbers . Ignore those which do not affect you. Circle any which seem to be a duplication ( There is a reason for the apparent ‘double-entry’).
Acne	Cracked lips
Alcohol cravings	Pale lips and possible white patches
Ankles jerk involuntarily	Irritability and depression
Depression	Overactive mind
Ankles swollen	Underactive mind
Ataxia	Menstrual cramps
Craving for bananas	Morning sickness
Backache	Moodiness
Disturbed balance	Dry mouth
Mood changes	Sores in corners of mouth
Tendency to bleed easily	Mouth sensitive to hot or cold liquid
High Blood pressure	Weak muscles
Aching bones	Tender muscles
Tender breasts	Muscles stiff or sore
Tendency to bruise easily	Muscles tremors or spasms or cramps
Sensitive to cold temperature	Muscles – loss of tone
Frequent colds or flu	Muscle twitches
Craving for cheese	Night blindness
Constipation	Brittle nails
Growing pains in childhood	White spots on nails
High cholesterol	Spoon shaped nails
Poor circulation	Nervousness
Poor dream recall	Electric shock feeling when neck bent
Dizziness	Lesions around nose
Diabetic or borderline	Red veins on nose
Ringing in ears	Nose bleeds
Earwax little or absent	Tendency to be overweight
Eczema	PMS symptoms
Low energy level	Pancreas problems
Painful eyes	Prostate problems
Red or burning eyes	Dry or red or inflamed skin
Dry eyes or tear ducts	Pale skin
Red Veins on eyes	Jumpy easily startled disposition
Gritty feeling in eyes	Dry scalp
Light sensitive in eyes	Low libido
Cataracts	Sensitivity to noise
Blue eye sockets especially against nose	Susceptible to stress
Easliy exhausted even after light exercise	Craving for sugar
Cold hands and/or feet	Excessive sweating
General fatigue	Inflamed or dry or greyish skin
Straw/yellowish skin colour	Pale skin
Swollen feet and/or ankles	Dry itchy , or flaking skin
Burning sensation on soles of feet	Permanent goose bumps or sand papery skin
Cold/numb hands or feet	Dry or scaly or discoloured skin
Tingling / numb hands and feet	Straw yellow skin
Stiff fingers/ bending difficulty	Red pimples or bleeding pimples on skin
Cravings for other foods	Stretch marks
Receding gums-possibly infected	Loose teeth
Inflammed or bleeding gums	Lots of plaque on teeth
Poor hair condition or loss	Poor sense of smell
Prematurely greying hair	Thyroid problems
Heart racing	Excessive thirst
Heart palpitations	Low body temperature
Irregular heartbeat	Tongue sensitive to hot fluids
Prickly-pins and needles hands /legs	‘Beefy’ red tongue
Hearing loss	Magenta red tongue
Tenderness / burning in heels	Deterioration of wisdom
Frequent infections of any kind	Painful wrist joints
Infertility	Easily out of breath
Tendency to arthritis/joint inflammation	Poor wound healing
Craving for ice	Pink urine after beetroot
Pain or stiffness in joints	Pubic area itching
Painful joints if teenager	Frequent yawning
Kidney Stones
Restless legs
Cramps in legs
Leg pain after exercise
Feeling listless

ADDITIONAL NOTES Please make mention of any other issues or symptoms of which you feel a consultant should be made aware or of any dietary or lifestyle issues about which you would like advice or coaching..