Questionnaire - Ultimate Health Check

CONFIDENTIAL HEALTH QUESTIONNAIRE

This questionnaire takes about 20 minutes to complete.
All fields marked with an asterisk (*) are required.

- Name*
- Gender*
  - Male
  - Female
- Height*
- Weight*
- Phone*
- Occupation
- Email*
- Children (Name/Dob)
- Address*
- GP's Name and Address
- Select DOB:*
  MM slash DD slash YYYY
- Refered by
- MAIN PRESENTING SYMPTOMS
- Click on the + button to create a new row
- SUPPLEMENTS/MEDICATION
- NAME OF PRODUCT BRAND NAME DOSE (AMOUNT/TIME OF DAY) REASON FOR TAKING DATE STARTED
- Click on the + button to create a new row
- TYPICAL DAILY DIET
- BREAKFAST
- BREAKFAST TIME
- SNACK
- SNACK TIME
- LUNCH
- LUNCH TIME
- SNACK
- SNACK TIME
- DINNER
- DINNER TIME
- SNACK
- SNACK TIME
- WATER INTAKE
- GENERAL FOOD CONSUMPTION
- PROTEIN
- PER DAY / WEEK / MONTH
- CARBOHYDRATES
- PER DAY / WEEK / MONTH
- Red Meat :
  - Beef
  - Pork
  - Lamb
  - Kangaroo
  - Deli Meats
  - Processed Meat
  - Other
- Per Day
- Per Month
- Vegetables :
  - Salad
  - Starchy
  - Greens
  - Other
- Per Day
- Per Month
- White meat :
  - Chicken
  - Turkey
  - Other
- Per Day
- Per Month
- Fruits :
  - Berries
  - Citrus
  - Stone Fruit
  - Apple
  - Bananas
  - Other
- Per Day
- Per Month
- Fish and seafood :
  - Canned
  - Fresh
  - Take Out
  - White
  - Salmon
  - Tuna
  - Sushi
  - Other
- Per Day
- Per Month
- Brown Fibre:
  - Whole Grain
  - Cereal
  - Pasta
  - Crackers
  - Bread
  - Other
- Per Day
- Per Month
- Eggs :
  - Organic
  - Free Range
  - Supermarket
  - Other
- Per Day
- Per Month
- White Fibre :
  - Bread
  - Biscuits
  - Crackers
  - Crisps
  - Cakes
  - Muffins
  - Pastries
  - Pies
  - Other
- Per Day
- Per Month
- Dairy products :
  - Cow
  - Sheep
  - Goat
  - Other
- Per Day
- Per Month
- Sweets :
  - Dark Chocolate
  - White Chocolate
  - Milk Chocolate
  - Lollies
  - Other
- Per Day
- Per Month
- Soy products :
  - Soy Sauce
  - Tofu
  - Soy Milk
  - Soy Yoghurt
  - Miso Soup
  - Other
- Per Day
- Per Month
- Sugar :
  - White Sugar
  - Brown Sugar
  - Honey
  - Maple
  - Agave
  - Stevia
  - Other
- Per Day
- Per Month
- Nuts and seeds :
  - Roasted
  - Raw
  - Salted
  - Almonds
  - Cashews
  - Peanuts
  - Brazils
  - Other
- Per Day
- Per Month
- Legumes :
  - Lentils
  - Baked Beans
  - Kidney Beans
  - Black Eyed-Peas
  - Other
- Per Day
- Per Month
- DRINKS
- PER DAY / WEEK / MONTH
- SMOKE & DRUGS
- PER DAY / WEEK / MONTH
- Alcohol :
  - Red Wine
  - White Wine
  - Cider / Beer
  - Champagne
  - Spirits
  - Other
- Per Day
- Per Month
- Smoke :
  - Cigarettes
  - Roll Ups
  - Cigars
  - Other
- Per Day
- Per Month
- Hot Drinks :
  - Coffee
  - Tea
  - Herbal Tea
  - Hot Chocolate
  - Other
- Per Day
- Per Month
- Illicit drugs :
  - MDMA
  - Coke
  - Hash
  - Grass
  - Other
- Per Day
- Per Month
- Cold drinks :
  - Soft Drink
  - Cordial
  - Diet Drinks
  - Juice
  - Other
- Per Day
- Per Month
- Follow specific diet? If so how long and the main reasons why?
- IgE and IgG Allergens
- IgE: Allergy
- If yes then what allergies do you have?
- IgG: Food sensitivity
- If yes then what intolerances do you have?
- STOOL AND URINE
- Are your stools:
  - Light/tanned, dark/tarry, green
  - Orange
  - Dark/tarry
  - Green
  - Presence of mucous
  - Blood or undigested food
  - Other
- Do you have:
  - Constipation/diarrhoea/mixture
  - Pain
  - Odour
  - Excessive flatulence
  - Itchy or burning anus
  - Haemorrhoids
- Which type on the Bristol Stool Chart?
- How often in a day?
- Has this changed recently?
- Bristol Stool Chart
  
  Type 1
  
  Separate hard lumps, like nuts (hard to pass)
  
  Type 2
  
  Sausage-shaped but lumpy
  
  Type 3
  
  Like a Sausage but with cracks on its surface
  
  Type 4
  
  Like a Sausage or snake, smooth and soft
  
  Type 5
  
  Soft blobs with clear-cut edges (passed easily)
  
  Type 6
  
  Fluffy pieces with ragged edges, a mushy stool
  
  Type 7
  
  Watery, no solid pieces entirely liquid.
- Digestion
- - Bad breath
  - Bleeding gums
  - Sore tongue
  - Mouth ulcers/cracked lips
  - White coating on your tongue or inner cheeks
  - Trouble swallowing
  - Heartburn/reflux, excess belching after food
  - Indigestion, food sits for hours
  - Nausea
  - Stomach pain
  - Vomiting
  - Bloating
  - Gas
  - Cramping
  - Liver problems
  - Gallstones
- Difficulty digesting some foods - which?
- Intolerance to certain foods/drink e.g. fats, alcohol - which?
- Crave certain foods - which?
- Gut has never been the same since bout of food poisoning/gastro - when/tests?
- Chemical sensitivities (e.g. car exhaust, petrol,cigarette smoke, perfumes, wine, cleaning products?)
- Additional information:
- Respiratory and Immune
- - Hay fever
  - Sneezing
  - Itchy eyes/nose/ears
  - Red or puffy eyes
  - Nasal /sinus congestion or mucous
  - Sore throat
  - Swollen glands
  - Asthma, wheeze or shortness of breath
- History of recurrent infection: ear infections, cold/flu, bronchitis, tonsillitis, urinary tract infections,others - what and how many?
- Number of antibiotics in last 12 months?
- Constant Cough, Sputum - colour?
- Do you smoke? How many per week?
- Exposure to pollution/chemicals/etc - what and how long for?
- Mind and Mental Health
- Have you felt the following symptoms consistently over the past few weeks:
  - Sad, empty or flat most of the time
  - Depressed
  - Emotionally raw, vulnerable, close to tears or anger
  - Lost pleasure in previously fun/satisfying activities
  - Excessive guilt
  - Excessive worry, nagging thoughts
  - Anxiety or fear
  - Restless, edgy or irritable
  - Indecisive
  - Self conscious
  - Any episode of Panic - shaking, sweating, blushing, difficulty breathing, fear
  - Rapid recent change to appetite, weight or sleep pattern
  - Do you tend toward perfectionism? For example: very high standards of neatness, order, social interaction,behaviour of others, feeling a great need for control / certainty
  - History: withdrawn as a teenager
- Energy & Endocrine
- Energy levels /10 (0 worst and 10 best they could be)?
- Stress levels (0 worse to 10 best)?
- - Crave caffeine or stimulants to spark up in the morning
  - Crave sugar/sweet foods, crave licorice
  - Emotionally sensitive, feel cope less well with stress than in the past
  - Feel tired, jittery or vague if meals are delayed
  - Feel confused shaky or weak under stress
  - Have gained weight around the middle /trunk
  - Increased thirst, increased urination, increased sweet cravings, sweating
  - Feels the cold easily, increased hunger, trembles, mentally tired
  - Low libido
- Sleep and Nervous
- - Sleep talking
  - Sleep Walking
  - Tooth grinding or jaw clenching(bruxism)
  - Difficulty remembering your dreams
  - Snoring (moderate to severe)
  - Waking up in the night with a snort, gasp or choking/breathless feeling
  - Restless legs
  - Work night shifts
  - Headache upon waking
  - Day naps
  - Poor memory/concentration
  - Low energy in afternoon
  - Often sleepy in the day
  - Difficulty falling asleep
  - Difficulty keeping asleep
- Heart and Circulation
- - Irregular heart rate
  - Chest pain
  - Elevated or low cholesterol
  - Vertigo or faint-headed
  - Dizziness when standing up suddenly
  - Cold hands or feet
  - Fluid retention or puffiness
  - Headache or migraine
  - History of Anaemia or B12 deficiency
  - History of Stroke, Heart Attacks
  - Pain in legs when walking/sitting/exercise
  - Varicose veins
  - Bruise easily
  - High or low blood pressure
- How many times wake up in night, what times and why?
- How many hours do you sleep per night (not total time in bed)?
- Skin, Nails and Hair
- - Slow healing of cuts
  - Easy bruising
  - Cracked corners of mouth
  - Dry, chapped or cracked lips
  - Regular cold sores or warts, mouth ulcers
  - Small bumps on upper arms
  - Skin conditions: acne, rash, itch, eczema, hives,dermatitis, dandruff, psoriasis, or de-pigmentation (vitiligo)
  - Athletes foot, jock or vaginal itching in the past 3 months
  - Dry skin
  - Brittle hair, thinning hair, Hair loss
  - Thinning brows
  - Flaky nails
  - Burning feet
- Musclo-skeletal - indicate where on diagram
- - Arthritis
  - Osteoporosis
  - Back pain
  - Stiffness
  - Cramping
  - Tingling/numbness
- Diagram
  Where? How Often?
  
  Click on the + button to create a new row
- Eyes
- - Glaucoma
  - Cataracts
  - Visual floaters
  - Discharge
- Ears
- - Itching, pain or discharge
  - Ringing in ears or tinnitus or hearing loss
  - Noise sensitive
- Exercise
- How often (mins/hours) do you exercise per week and what type?
- Hormonal health - Female
- If you are female and menstruating please describe your period:
- Cycle length (e.g. 28-30d):
- How many days of bleeding:
- Heavy, moderate or light flow:
- Have you been on the oral contraceptive pill for more than 5 years continuously in your life?
- Are you pregnant or intending on conceiving soon?
- Are you breastfeeding?
- Please tick any symptom you have experienced in the last few months
- - PMS - mood changes
  - Cyclic headaches
  - Water retention
  - Breast tenderness
  - Breasts with lumps or cysts
  - Endometriosis/adenomyosis
  - Pelvic cramps
  - Painful intercourse
  - Excess weight around thighs or hips
  - Hot flushes
  - Night sweats
  - Vaginal dryness / pain on intercourse
  - Irregular or no period
  - Clotting / unusual discharge
  - Frequent urinary tract infections
  - History of or current PCOS
  - Increased or darkened facial hair
  - Excess hair on arms
  - Voice change
- History abnormal pap smear - what and when?
- If you are female: Please tick any that apply
- - Miscarriages / Terminations
  - Hysterectomy
  - Tubal ligation
- Post-menopausal - when was your last period?
- Hormonal health - Male
- If you are male: Please tick any that apply
- - Difficulty achieving an erection or softer erections
  - Takes longer to achieve orgasm
  - Premature ejaculation or inability to ejaculate
  - Elevated PSA
  - Prostate enlargement
  - Loss of muscle strength
  - Low-normal testosterone on blood test
  - Fasting blood sugar above 5.5 or type 2 diabetic
  - History of infertility
  - 2-3 nightly urinations
  - Testicular pain
- Other Factors
- Have you ever been to hospital and why?
- History
- Please tick any relevant conditions for you and/or immediate family i.e. Brother, Sister, Mother, Father, Grandparents
- Cancer or benign tumour
  - Me
  - Family
- Diabetes type 1, type 2
  - Me
  - Family
- Heart disease including elevated cholesterol, Coronary artery disease, Hypertension, History of heart attack or stroke, Deep vein thrombosis, Valve disorders, Elevated homocysteine
  - Me
  - Family
- Obesity
  - Me
  - Family
- Bowel disease- ulcerative colitis or Crohn's disease, IBS, coeliac, Other
  - Me
  - Family
- Infection: hepatitis, glandular fever, Ross river fever, rickettsia, malaria, blastocystis hominis, dientamoeba fragilis, H pylori, Giardia, other
  - Me
  - Family
- Allergy - sinus, hayfever, asthma, anaphylaxis, hives, eczema, food allergy or intolerance
  - Me
  - Family
- Autoimmunity - Rheumatoid arthritis, Sjogrens,Lupus (SLE), grave's, hashimotos, multiple sclerosis
  - Me
  - Family
- Thyroid illness of any kind
  - Me
  - Family
- Haemochromatosis (excess iron)
  - Me
  - Family
- Neurological disorders such as seizures, dementia,Alzheimer's, Parksinson's
  - Me
  - Family
- Mental health: anxiety, eating disorder, depression, OCD, schizophrenia, bipolar, personality disorder, ADHD or learning disorder
  - Me
  - Family
- Addictions: drugs, alcohol, gambling,sex
  - Me
  - Family
- Do any other significant medical conditions or symptoms run in, or are present in, your family?
- Other Stressors
- Are there any factors that you believe may have contributed to the change in your health?
- - High levels of stress
  - Moved house / location / living situation
  - Change in job/position / career
  - Sleep deprivation / shift work
  - Long or difficult work
  - Strenuous exercise
  - Change in lifestyle, e.g. diet, change to intake of coffee, cigarettes, or alcohol
  - Dental work
  - International travel
  - Loss, grief, death or illness inthe family
  - Viral or bacterial infection (other than typical 'cold'/ fever)
  - Hormonal change such as pregnancy, loss of pregnancy, baby, IUD insertion, menopause
  - Change in significant relationship or family friendship dynamic
  - Mould, dust or damp in home or workplace
- Anything else that may be relevant?
- Declaration*
  - I declare to the best of my knowledge, that the information provided by me, to be true and correct. I accept responsibility for all my consultations. I agree to cancel/change appointments with 1 week's notice period otherwise I accept that a cancellation fee may be imposed.
- GDPR Policy*
  - I consent to ultimatehealthcheck.com handling and storing my data submitted with this form as detailed in their GDPR policy here: http://ultimatehealthcheck.com/privacy-policy/
- Submitted By*
- Submitted Date*
  MM slash DD slash YYYY

NAME OF PRODUCT	BRAND NAME	DOSE (AMOUNT/TIME OF DAY)	REASON FOR TAKING	DATE STARTED

Where?	How Often?

CONFIDENTIAL HEALTH QUESTIONNAIRE

Bristol Stool Chart

If you are female and menstruating please describe your period:

Please tick any symptom you have experienced in the last few months

If you are female: Please tick any that apply

If you are male: Please tick any that apply

Please tick any relevant conditions for you and/or immediate family i.e. Brother, Sister, Mother, Father, Grandparents

Are there any factors that you believe may have contributed to the change in your health?