Brain Nutrition Questionnaire

The questionnaire is designed to provide your nutritionist with the information necessary to build a nutritional programme specifically tailored to your needs. Please answer the questions as accurately as you can.

This questionnaire consists of 4 pages and requires several minutes to fill in. If submitting online, you must be able to do so in one go, in which case you may fill in your food intake (on last page) for any 2 recent days.

Should you prefer to complete the questionnaire by hand and send it to us by post, the word document file can be downloaded here.

Fields marked with * are required.

Client Details

First name: *
Last name: *
Address:
Post code: *
Telephone number(day): *
Telephone number(evening):
Mobile number:
Email:
Occupation:
Date of birth: *	(dd/mm/yyyy). Please include slash. i.e 17/01/1970
Weight(without clothes):
Height(without shoes):
Blood group(if known):

G.P./Psychiatrist details
Name:
Telephone number:
Address:
Name and phone of relative or other Support Person (if appropriate):
Name:
Telephone number:

Health profile

Please list all the problems you would like to clear up and indicate for how long you have had these problems eg: depression 3 years

Health problem		Duration
1.
2.
3.
4.
5.
6.

Under what circumstances do these problems improve?
Under what circumstances do do they get worse?
List other illnesses that you have had in the past ten years:
What operations have you had?
Blood pressure (if you know):		Pulse:

Family history

Relationship to client	Prone to following illness	Relationship to client	Prone to following illness