Questionnaire

Personal Details

Weight History

Weight loss History

Family Medical History

Ladies

Do you have regular periods (26 - 33 days)

Do have problems with excessively heavy periods

Surgical History

Personal Medical History

Diabetes

Asthma

Respiratory

Artritis

Back Pain

Kidney or urinary disorder

Neurological

Psychological/nervous disorder

Gallstones

Reflux or heartburnl

Gastric or duodenal ulcer

Hepatitis or liver disease

High blood pressure

Heart disease

High cholesterol

Anaemia or bleeding disorder

Thrombosis or clotting disorder:

Varicose veins or leg swelling

Eczema or skin condition

Hayfever or Rhinitis

Please give details of any major illnesses/problems
MEDICATIONS

Medication for psychiatric disorder

Migraine medication

Medications to assist weight loss

Drugs for epilepsy

Drugs for asthma or breathing:

Hormones:

Cortisona

GASTROESOPHAGEAL REFLUX / INDIGESTION