Questionnaire

Declaration
I fully understand the explanation of the treatment I am about to receive. I accept that the practitioners are not medical doctors and if I have any symptoms of a medical nature I have already consulted my doctor before deciding to undergo any alternative therapy. This is solely my decision to go ahead with the treatments recommended and does not replace any medical advice already given by my doctor. I understand that Beechcroft Retreats is a holistic establishment and the practitioners are naturopathic consultant and not medical doctor. We do not treat/cure cancer, all prescribed Medication should be taken as advised and is your responsibility. No personal care will be provided, if required this must be arranged by the clients carer/family. No phones will be allowed to be used, in an emergency we can arrange calls on request. All information that I will provide is accurate and to the best of my knowledge.
Signed:
Date

DD
MM
YYYY
Personal Details
Title
First Name
Surname
Date of birth

DD
MM
YYYY
Contact details
Address
Street Address City Postcode
Telephone number
Mobile number
Email
Medical details
Height
Weight
Blood type
Referred by
Is there a family history of any of the following
- Cancer
- Heart Disease
- Nervous or Mental Disorders
- Stroke
If yes, please give details
Do you currently have or ever had any or the following medical conditions?
1. Epilepsy, fits, blackouts, fainting turns or unexplained loss of consciousness
- Yes
- No
2. Head Injury leading to loss of consciousness requiring hospital admission
- Yes
- No
3. Recurrent Headaches or Migraines
- Yes
- No
4. Disease of the nervous system e.g. Neuritis, Stroke, Multiple Sclerosis
- Yes
- No
5. Injury or surgery to your eye/s including corrective laser surgery or any type of refractive surgery
- Yes
- No
6. Any visual defects e.g. Scotoma, Blindness in one eye, Night blindness, Colour blindness, Reduced visual field, Blurred vision, Detached retina
- Yes
- No
7. Any eye disease or condition such as Glaucoma or Retinitis
- Yes
- No
8. Ear Infection, Discharge, Tinnitus, a hearing defect inc deafness
- Yes
- No
9. Vertigo, Dizziness, Giddiness, Problems with balance
- Yes
- No
10. Chest pain, Angina, Heart Disease or Breathlessness
- Yes
- No
11. Varicose Veins or Circulation Problems
- Yes
- No
12. Rheumatic Fever
- Yes
- No
13. High, Low or Raised Blood Pressure
- Yes
- No
14. Any Blood Disorder
- Yes
- No
15. Asthma, Bronchitis, Emphysema, Pleurisy, Pneumonia or any other Lung Disease inc TB or Pneumothorax
- Yes
- No
16. Recurrent Nausea, Dyspepsia, Heartburn, Indigestion or Hiatus Hernia
- Yes
- No
17. Gastric, Duodenal or Peptic Ulcer
- Yes
- No
18. Inflammation of the Bowel inc Crohn’s Disease, Ulcerative Colitis, Bleeding from the Rectum or Diarrhoea lasting more than one week
- Yes
- No
19. Irritable Bowel Syndrome (IBS)
- Yes
- No
20. Jaundice or any other form of Hepatitis or other Liver Problems
- Yes
- No
21. Any other Abdominal Complaint including Hernia
- Yes
- No
22. Kidney Stones
- Yes
- No
23. Recurrent Kidney or Urinary Tract Infection e.g. Cystitis and Urethritis, Blood in your Urine
- Yes
- No
24. Any other Kidney or Bladder Conditions
- Yes
- No
25. Any problems with boned or joints including back, neck and knee, Sciatica, any fracture or recurrent dislocation of a major joint
- Yes
- No
26. Have you ever consulted an Orthopaedic Surgeon, Chiropractor, Osteopath or Physiotherapist?
- Yes
- No
27. Have you ever been diagnosed as having Arthritis, Gout, Chondromalacia Patellae or Rheumatism?
- Yes
- No
28. Psoriasis, Eczema, Allergic Skin Rash or other skin disease
- Yes
- No
29. Any Metabolic disorder including Diabetes, thyroid and Adrenal Gland Disease or other Glandular Disorder
- Yes
- No
30. Any Disorder of Reproductive Organs Inc Gynaecological, Testicular and breast problems
- Yes
- No
31. Any Infectious Disease (apart from childhood illnesses) inc Sexually Transmitted Disease or Tropical Disease
- Yes
- No
32. Anxiety or Depression, Phobias, Mental Breakdown or Stress Related Problems
- Yes
- No
33. Any other Mental Illness
- Yes
- No
34. Any Eating Disorders e.g. Anorexia Nervosa or Bulimia
- Yes
- No
35. Any Allergies inc Hay Fever
- Yes
- No
36. Any Operations or Surgical Procedures
- Yes
- No
37. Any Malignancies or Cancers
- Yes
- No
38. Any unexplained Weight Loss in the past year
- Yes
- No
39. Are you currently undergoing any treatment, or are on any medication?
- Yes
- No
40. Amalgam Fillings
- Yes
- No
41. Social Diseases (Herpes, Venereal, HIV)
- Yes
- No
42. Do you have any white spots and horizontal ridges on finger/toe nails?
- Yes
- No
43. How often do you get colds and flu in a year?
(Approximate)
44. How many courses of antibiotics have you been on so far?
(Approximate)
If you have answered ‘YES’ to any of the above or if you believe there is anything else you would like us to know, please give details
Do you smoke?
- Yes
- No
Do you drink Alcohol?
- Yes
- No
If yes, how many units do you drink a week?
Do you Exercise?
- Yes
- No
If yes, how much per week?
Do you have regular Bowel Movements
- Yes
- No
(1 to 2 times per day)
Is Your Menstrual Cycle regular?
- Yes
- No
Do you take Birth Control pills?
- Yes
- No
If so for how long?
Do you take Vitamins & Minerals?
- Yes
- No
If yes, which ones?
Tick any of the below that you suffer from
General
- Headaches
- Insomnia (Loss of Sleep)
- Loss of Weight
- Dizziness
- Fainting Spells
- History of Seizures
- Fatigue
- Depression
- Enlarged thyroid
- Double or Blurred Vision
Genito Urinary
- Kidney Infection or Stones
- Painful Urination
- Prostate trouble
- Kidney Trouble
Cardiovascular
- High Blood Pressure
- Hardening or the Arteries
- Angina (chest pain)
- Poor Circulation
- Irregular Heart Beat
- Congestive Heart Failure
- Swelling
Muscle & Joint
- Arthritis
- Bursitis
- Lower Back Pain
- Neck Pain
Skin
- Bruise Easily
- Dryness
- Itching
- Rash
Women
- Painful Menstruation
- Last Menstrual /Period Date
- Vaginal Discharge
- Breast Pain
- Are you Pregnant
- Other Pains
- Swollen Joints
Gastro-intestinal
- Colitis
- Constipation
- Crohn’s Disease
- Ulcerative Colitis
- Diverticulitis
- Gall Bladder Disease
- Haemorrhoids
- Fissures/Fistula
- Cirrhosis
- Rectal Bleeding
- Vomiting Blood
- Cancer
- Family Colon Cancer
- Diarrhoea
Respiratory
- Shortness of Breath
- Chronic Cough
- Coughing up Blood
- Emphysema
- Bronchitis
- Asthma (wheezing)
- Hay Fever
- Sinus Problems
Dietary
Please describe briefly what you eat for
Breakfast
Lunch
Dinner
Comments
This field is for validation purposes and should be left unchanged.

Questionnaire

Declaration

Personal Details

Contact details

Medical details

Do you currently have or ever had any or the following medical conditions?

Tick any of the below that you suffer from

Dietary