Name
*
First Name
Last Name
Email
*
Please confirm email
*
Phone number
*
Date of birth
*
MM
DD
YYYY
Sex
*
Please select an option
Female
Male
Prefer not to say
Occupation
Weight
Height
Blood group
Colour of the eyes
Reason(s) for arranging a consultation
The more details the better!
Have you ever met with a naturopath before?
What do you wish to achieve from the session?
Marital status
Do you have children?
Current professional situation
Please select an option
Employee
Self-employed
Retired
Unemployed
Stay-at-home parent (yes, it definitely is a job!)
Other
How would you describe your work atmosphere?
How do you commute to work? How long does it take you to get to work?
Do you have any more comment about your working conditions?
Do you smoke?
Do you take recreational drugs?
Do you consume alcohol?
How many hours of sleep do you get on average?
How would you describe the quality of your sleep?
Do you suffer from insomnia?
Do you take any sleeping aid?
Sleeping tablets / herbal tea / other.
Do you feel stressed?
Are you an anxious person?
Please select an option
Yes
No
Not sure
Do you suffer from panic attacks?
Please select an option
Yes
No
Not sure
Do you suffer from mood disorders / mood swings?
Please select an option
Yes
No
Not sure
Do you suffer or have you ever suffered from depression in your life?
Do you find it difficult to concentrate / focus on a task?
Do you suffer from any other emotional / mental symptoms?
What is your level of energy?
Do you practice a sport or any physical activity?
Do you practice any relaxing activity?
Do you take a medical treatment?
Do you take supplement(s) on a regular basis?
Have you ever had surgery?
Did you have any medical screening in the last 6 months?
Blood test, mammography, fibrescopy, x-ray, MRI…
Have you had vaccination within the last 2 years?
Did you have any childhood illnesses?
Do you suffer from any allergies?
From birth to 10 years old
From 11 to 20 years old
From 21 to 30 years old
From 31 to 40 years old
From 41 to 50 years old
From 51 to 60 years old
From 61 to 70 years old
From 71 to 80 years old
From 81 to 90 years old
Medical family background
Now describe your family background (genetic inheritance, heart attacks, cancers, diabetes, osteoarthritis, mental illnesses, etc. Pregnancies for women).
Migraines / headaches
Catarrh (mucus / inflammation of nose and throat)
Hay fever
Sneezing
Eyes inflammation
Mouth ulcers
How does your skin feel like?
Please select as many options as you like.
Skin conditions
Herpes, acne, psoriasis, eczema…
Nails
Please select an option
Hard
Soft
Brittle / easily break
Asthma
Muscles / bones
Back pain, stiffness, pain, tensions, sprains, joints, swelling, fractures...
Weight
Steady, obesity / thinness, eating disorders, sudden weight loss / gain...
Blood pressure
Cholesterol
Are you sensitive to cold?
Are you dreading winter because you get sick easily and feel uncomfortable at that time of the year?
Chronic issue(s)
Rhino, bronchitis, sinusitis, ear infection, sore throat...
Diabetes
Thyroid issues
Other
Anything else that hasn't been covered above and that is worth mentioning.
Urinary tract infections
What type of birth control do you use?
How would you describe your menstrual cycle?
Do you suffer from vaginal thrush?
How would you describe your libido?
Do you suffer from andropause?
How healthy are your teeth?
Please select as many options as you like.
Do you chew your food properly?
How is your digestion?
Please select as many options as you like.
Do you feel tired after meals?
How often do you go to the toilets?
How would you describe your stools?
Please select as many options as you like.
Other
Anything else that hasn't been covered above and that is worth mentioning.
Food allergies
Food intolerances
Special diet
Vegetarian, vegan, gluten-free, raw....
Please describe your usual type of breakfast
Please describe your usual type of lunch
Please describe your usual type of dinner
Do you snack?
How often do you eat out?
What is your favourite taste?
Do you drink water throughout the day?
What type of water do you usually drink?
Please select as many options as you like.
Do you like cooking?
What type of dairy products do you ususally have?
Please select as many options as you like.
Do you consume a lot of salt?
What are your favourite foods?
Is your appetite in relation with your physical activity?
Do you have any food cravings?
Please select as many options as you like.
Do you suffer from any eating disorder?
Do you consume organic products?
What type of sugar do you normally use?
Please select as many options as you like.
What type of bread, rice and flour do you normally use?
Please select as many options as you like.
What type of oil do you normally use?
Please select as many options as you like.
What do you usually consume?
Please select as many options as you like.
Do you consume any of the following products?
Please select as many options as you like.
Coffee
Tea / herbal tea
Fruit juice / soda
Wine
Beer
Other type(s) of alcohol
Milk / yogurt / other types of dairy desserts
Cheese
Fish
White meat
Chicken, pork...
Red meat
Cured meat
Fresh / frozen vegetables
Fresh fruit
Starchy foods
Bread, rice, pasta, potatoes...
Legumes
Chickpeas, beans, lentils...
Pastries / cakes / desserts
EXCEPT FRUIT / FRUIT PURÉE or COMPOTE
Is there anything else that hasn't been covered and that you would like to add?
