Your questionnaire

Personal nutrition advice plan

Welcome to your questionnaire.
Please tick all that apply to you and provide more details where indicated. The fields marked with an asterisk (*) are compulsory and must be completed. If you need information about how the advice plan works, click here

Please note that this questionnaire is not suitable for anyone with AIDS, cancer, multiple sclerosis, Parkinson’s, epilepsy or glaucoma.

  Name*
  Email Address*
  Country*
  Date of Birth* (dd/mm/yyyy)
  Height* (indicate feet/inches or cms)
  Weight* (indicate stones/pounds or kgs)
  Gender* Female      Male


  Do you currently have a diagnosis of:
  Irritable Bowel Syndrome Diverticulitis Crohn’s Disease or Colitis
  Stomach or duodenal ulcer Arthritis Osteoarthritis
  Rheumatoid arthritis Ankylosin Spondylitis Osteoporosis
  Heart disease Diabetes Depression
  Underactive or overactive thyroid    
  Other - please give details ===>


  Is there a history of heart disease or diabetes in your family? Yes      No
     
  Do you know if you have any food allergies or intolerance? Yes      No
  If yes, please give details ===>
     
  Do you have anorexia or bulimia? Yes      No
     
  Are you on medication? Yes      No
  If yes, please give details ===>
     
  Do you smoke? Yes      No
  If yes, please give details ===>


  Please tick all that apply:
       
  Lack of energy Energy dips during the day Crave coffee, tea, cola
  Mood swings Trouble concentrating Get very thirsty
  Frequent thrush Gain weight and find it hard to lose  
  Crave sweet foods, bread, cereal or pasta
  Get irritable, nauseous or dizzy if you don’t eat frequently
 
  Depression Nervousness, anxiety or tension Tired or irritable
  Crying spells Feel sad, particularly in the morning Apathy
  Poor appetite Feel unlovable Pessimistic
  Insomnia Panic attacks Premenstrual tension (women only)
  Major personal loss or trauma in the last year
 
  Indigestion/uncomfortable after a meal Bloating Diarrhoea
  Constipation Bad breath Often feel nauseous
  Flatulence Less than one bowel movement per day
 
  Get stressed Exercise less than twice per week More than three colds per year
  Asthma Eczema Hayfever
  Psorosis Dermatitis Acne
  Aches and pains Headaches Migraines
  Excessive mucous Furry tongue Ear infections
  Haemorrhoids Have frequent or prolonged infections (tummy bugs, colds)
  Have taken anti-biotics more than once in the last year
  Allergies - please give details ==>
 
  Have a stressful life Blood pressure over 140/90 (if known)
  Get out of breath easily Eat high fat foods frequently  
  Eat less than three servings of fruit and vegetables each day
  Please give cholesterol level (if known)...
 
  Fatigue Pale complexion Intolerance to cold
  Concave nails or trenches across nails Slow wound healing Loose teeth or bleeding gums
  Bruise easily Night blindness Dry eyes
  Dry skin Dry hair Broken fingernails
  Muscle cramps    


  Women only:
  Currently on contraceptive pill or HRT or been on for more than three years
  Cyclical mood swings Any problems related to ovaries or womb
  Irregular or heavy periods Sweats, hot flushes, weight gain
     
  Men only:
  Any problems related to reproductive organs Trouble urinating
  Reduced libido Impotence


Thank you for completing your questionnaire.
You have now taken the first step to a healthier life!

Please check your answers and then click on the submit button below. The data will be sent to Nutri-libra.


The next screen will tell you how to make a PayPal payment of £29
for your personal nutrition advice plan.