First Name
Surname
DOB
Email
Symptom Severity / Frequency
0 = Never
1 = Mild or Infrequent Symptoms (twice per week or less)
2 = Moderate or Frequent Symptoms (3-6 times a week)
3 = Severe or Daily Symptoms
Tip
If your response is Never (0) you do not need to click this in and you can leave that question blank. If however you do change your mind for example from Mild (1) to Never (0) you will need to click.
1. Curved spine, height loss, stooped base of neck hump (dowager’s hump) 0123
2. Bone pain, back, hip or knee pain 0123
3. Spinal problems, pain, Sciatic pain 0123
4. Osteoporosis 0123
5. Recent broken bones, fractures 0123
6. Arthritis - Osteo/Rheumatoid 0123
7. Joints swelling painful, deformity, injury, stiffness 0123
8. Noisy joints (creak, grind etc.) 0123
9. Nodules on fingers 0123
10. High uric acid level / Gout 0123
11. Damaged disc, slipped disc 0123
12. Bursitis or tendonitis 0123
1. Tightness or pain in back, neck or shoulder muscles 0123
3. Stiffness in muscles 0123
4. Tenderness, pain in muscles 0123
5. Weakness in muscles 0123
6. Trembling (fasciculation) 0123
1. Chest tightness on stress or exertion 0123
2. Palpitations, arrythmias, extra beats 0123
3.Swelling of the ankles 0123
4. Shortness of breath on exertion/rest 0123
5. Calf pain on exercise 0123
6. Dizziness on exertion 0123
7. Previous angina attacks, heart attack or stroke 0123
8. Known cardiac murmur or condition 0123
9. High blood cholesterol, triglycerides or blood clotting problems 0123
10.Blood Pressure or Heart medication 0123
1. Blue, numb, cold fingers or toes YesNo
2. Ulcers, sores on legs and feet YesNo
3. Shiny, discoloured, hairless skin on arms or legs / Varicose veins YesNo
4. Cramps, pain in legs when walking 0123
5. Pins and needles, numbness - hands, feet 0123
6. Fluid retention feet, legs, body 0123
7.Difficulty with written or spoken words or concentration 0123
8. Dizzyness, ringing in the ears 0123
9.Fleeting nausea / Hearing loss 0123
10. Previous deep vein thrombosis YesNo
11. Take Anti-clotting medication YesNo
1. Morning headaches 0123
2. Feel tired, nervy, weak 0123
3. Ringing in ears / Sleepy, dizzy 0123
4. Flushing with no known cause 0123
5. Tingling and numb hands and feet 0123
6. Blurry vision 0123
7. Hi Blood Pressure / Heart medication YesNo
1. Smoker YesNo
2. Cough 0123
3. Asthma, Wheezing 0123
4. Repeated chest infections / Gets chest infections easily 0123
5. Shortness of breath on effort or at rest 0123
6. Chest pain on breathing or coughing 0123
7. Coughing up mucus/phlegm 0123
8. Takes asthma medication YesNo
1. Burping up gas 0123
2. Bloating after meals 0123
3. Abdominal distention, swelling 0123
4. Less than 1 bowel movement per day 0123
5. Food intolerances, allergies 0123
6. Foul smelling breath 0123
7. Low vitamin B12 levels YesNo
8. Acne or Acne Rosacea 0123
9. Eczema 0123
10. Flaking, peeling or brittle nails 0123
1. Past duodenal ulcers, stomach problems YesNo
2. Do you have an ulcer now ? YesNo
3. Do you use antacids ? YesNo
4. Stomach pains on lying down or bending after a meal 0123
5. Stomach symptoms, heartburn, pain 0123
6. Food, drink makes stomach feel better 0123
7. Black stools (blood) 0123
8. Helicobacter breath test positive YesNo
1. Abdominal cramps after eating meals 0123
2. Abdominal cramps opening bowels 0123
3. Loose stools, constipation 0123
4. Tiredness after meals 0123
5. Smelly stools 0123
6. Acne, Food allergies 0123
7. Inflammation of the small bowel 0123
8. Mucous in stools 0123
9. Fullness, indigestion for 2-4 hrs after meals 0123
10. Bowel gas, flatulence, wind 0123
1. Chronic fungal infections, thrush, parasites abnormal bacteria 0123
2. Low fibre diet 0123
3. Constipation, diarrhea, colitis 0123
4. Antibiotic use (note frequency) 0123
5. High meat intake 0123
6. Abdominal pain, Diverticulitis 0123
7. Bowel gas, flatulence, wind 0123
8. Abdominal pain, Diverticulitis / Diverticulosis 0123
9. Changeable bowel habits 0123
10. Red blood in stool (or blood found in stool on testing) 0123
1. Indigestion, pain or nausea after eating or nausea after drinking alcohol 0123
2. Previous hepatitis or abnormal liver function tests YesNo
3. Pain under front right side of rib cage, right side of back 0123
4. Yellowness of sclera (whites of eyes) 0123
5. Indigestion or pains after fatty food 0123
6. Light coloured stools, dark urine 0123
7. High cholesterol or triglycerides 0123
8. Strong smelling urine after eating asparagus YesNo
9.Gallstones, pain under right hand side of rib cage 0123
10. Irritability, depression, foggy thinking 0123
11. Reddened palms or skin 0123
12. Fatigue, tired all the time, generally feels unwell 0123
1. Poor sense of smell and taste 0123
2. Dark under the eyes, on cheeks 0123
3. Cold sores, herpes, HPV, HIV YesNo
4. Catch colds and flu easily YesNo
5. Nasal blockage, mucus, post nasal drip, sore throat 0123
6. Frequent antibiotic use 0123
7. Ear, nose, throat, eyes, lung, skin infections 0123
8. Discharge from ears 0123
9. Swelling in groin, armpits, neck 0123
1. Hayfever, sinusitis 0123
2. Headaches & Migraine 0123
3. Eczema, psoriasis, dermatitis 0123
4. Urticaria (hives) YesNo
5. Arthritis (osteo, rheumatoid) 0123
6. Itching or red eyes 0123
7. Mouth ulcers 0123
8. Sensitive to chemicals YesNo
9. Hyperactive, ADD, ADHD, Learning difficulties YesNo
10. Asthma, wheezing YesNo
11. Chronic cough/hoarseness 0123
12. MS, SLE, other autoimmune diseases YesNo
1. Fatigue, tired all the time 0123
2. Poor tolerance to stress 0123
3. Salt cravings 0123
4. Poor exercise tolerance 0123
5. Food sensitivities 0123
6. Environmental pollutant sensitivity 0123
7. Feels dizzy, blurry vision when rising or standing up 0123
8. Irritability, rapid mood swings 0123
9. Slow recovery from infections 0123
10. Changes in skin pigmentation, colour 0123
1. Sensitive to cold 0123
2. Depression 0123
3. Fatigue 0123
4. Constipation 0123
5. Dry skin 0123
6. Fluid retention 0123
7. Loss of hair anywhere on the body 0123
8. Difficulty in losing weight 0123
1. Sweating if food is delayed, irritability if meals are missed 0123
2. Frequent copious urination and increased thirst 0123
3. Tremors or shakiness if meals missed 0123
4. Dizziness after sugary food or drink 0123
5. Craving coffee or stimulants 0123
6. Headaches if meals are missed 0123
7. Poor memory 0123
8. Eating relieves symptoms 0123
9. Difficulty in losing weight or slow recovery from infections 0123
10. Immediate family member has a history of diabetes YesNo
1. Bed wetting 0123
2. Frequent urination 0123
3. Frequent infections 0123
4. Blood or protein in urine 0123
5. Puffy eyelids 0123
6. Antibiotics for urinary infections 0123
7. Polyps in urethra or bladder 0123
8. Strong smelling urine 0123
9. Dripping after or poor urine stream 0123
10. Incontinence on exertion, sneezing etc. 0123
1. Low libido 0123
2. Premature ejaculation 0123
3. Difficulty developing or maintaining an erection 0123
4. Burning on urination 0123
5. Aching at back of legs, rectal area 0123
6. Difficulty in urinating, dripping after urination 0123
7. Low sperm number and / or motility 0123
8. Previous sexually transmitted disease YesNo
9. Varicocele YesNo
10. Blood or other discharge from penis YesNo
11. Genital warts / lesions YesNo
1. Light headedness/vertigo 0123
2. Walking difficulties 0123
3. Poor bowel / bladder control 0123
4. Speech difficulties 0123
5. Weakness of limbs 0123
6. Muscle twitching 0123
7. Sensory, perception changes - temperature, numbness, tingling 0123
8. Short / long-term memory loss 0123
9. Poor co-ordination / balance 0123
10. Paralysis, spasticity YesNo
1. Cerebravascular - Stroke, transient ischaemic attacks, haemorrhage YesNo
2. Alzheimer’s disease senile dementia YesNo
3.Tremor 0123
4. Parkinson’s disease YesNo
5. Weakness of limbs YesNo
6. Muscle twitching YesNo
1. Chronic pain at any site 0123
2. Headaches, migraines, cluster headaches 0123
3. Neuralgia - Trigeminal following herpes/shingles infection 0123
4. Addiction to recreational drugs YesNo
5. Difficulty giving up smoking YesNo
6. Need to have at least one alcoholic drink each day YesNo
7. Reflex sympathetic dystrophy YesNo
8. Chronic arthritis 0123
9. Food addiction/ anorexia/ bulimia YesNo
10. Depends on medication for pain YesNo
1. Forgetful 0123
2. Difficult concentration 0123
3. Treated for schizophrenia YesNo
4. Depression YesNo
5. Obsessive compulsive disorder YesNo
6. Easily distracted, learning problems 0123
7.Suicidal thoughts YesNo
8. Anxiety, Waking with anxiety YesNo
9.Panic Attacks YesNo
10. Mood swings 0123
1. Vivid dreams 0123
2. Light sleep 0123
3. Sleep talking 0123
4. Sleep walking 0123
5. Snoring (sleep apnoea) 0123
6. Difficulty falling asleep 0123
7. Early morning waking 0123
8. Frequent waking 0123
9.Wake during night with difficulty getting back to sleep YesNo
10. Waking up exhausted 0123
