About The Retreat
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MAKE AN ENQUIRY
About The Retreat
NEXT RETREAT
The Stress Reset (ONLINE)
Bespoke Retreats
Reviews
TIPS & RECIPES
MAKE AN ENQUIRY
Nutritional questionnaire
Name
*
First Name
Last Name
Email
*
Phone Number
Date Of Birth
*
MM
DD
YYYY
Sex
*
Female
Male
Weight
*
Height
*
Tick your top three health concerns
digestion improvement
weight management (loss or increase)
sugar or carbs addiction control
energy improvement
immunity increase or improvement
sleep management
skin improvement
hormonal balance
other
If other, please explain
What medications are you currently taking and what are they for?
Have you taken steroids in the last year and if so what for?
Have you taken a course of antibiotics in the last year if so what for?
Please detail all serious injuries, illnesses, infections and organ removal (tonsils, hysterectomy etc.) specifiying what and when
How many mercury or other metal fillings do you have?
How many cigarettes do you smoke per day?
How many times a day do you consume sugar?
How many portions of processed food do you consume a week?
How many portions of red meat do you consume a week?
How many cups of tea / coffee or caffeinated drinks (i.e. cola) do you drink per day?
How many glasses of water / herbal teas / pure unsweetened fruit juice do you drink per day?
Do you consider yourself to be overweight and if so by how much?
Please assess your personal stress level – 0 being NO stress and 10 being highly stressed.
How many times per week do you have a bowel movement?
How many times per week do you exercise for 20 minutes or more and what form does this exercise take?
List what you eat on a typical day. Do you add salt?
Do you take any supplements (vitamins/herbs etc)?
Please see the list of symptoms below and tick any that apply to you
Headaches
Dizziness
Insomnia
Faintness
High blood pressure
Frequent Illness
Frequent or urgent urination
Digestive tract
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn, reflux
Intestinal/stomach pain
Weight
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Energy
Fatigue, tired, sluggish
Apathy, lethargy
Hyperactivity
Restlessness
Skin
Acne
Hives, rashes, dry skin, psoriasis, eczema
Hair loss
Flushing
Excessive sweating
For Women only - Hormones
Heavy, painful periods
PMS symptoms
Menopausal symptoms
Irregular menstruation
Absence of menstruation
Eyes
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near or far-sightedness)
Ears
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, popping ears, hearing loss
Nose
Stuffy nose
Sinus problems
Sneezing attacks
Excessive mucus formation
Hay fever
Joints / muscles
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Tell us about your current food sensitivities. Do you eat Wheat?
Please tick what applies to you
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I don't feel good afterwards
I feel fine afterwards
Do you eat gluten?
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I don't feel good afterwards
I feel fine afterwards
Do you eat grains (rye, spelt, rice, buckwheat, oat)?
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I don't feel good afterwards
I feel fine afterwards
Do you eat dairy?
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I dont feel good afterwards
I feel fine afterwards
Do you eat soy?
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I don't feel good afterwards
I feel fine afterwards
Do you eat eggs?
No
Under 3 times per week
Over 3 times per week
It brings discomfort
I don't feel good afterwards
I feel fine afterwards
Thank you!
