Dr Peatfield’s Questionnaire
The Peatfield Clinic Metabolic Health Questionnaire
Telephone Number: Mobile No: …
Sex: q M q F Date of Birth: . Age: No. of Children (if any):
Relationship Status: (please tick) qMarried/Living with Partner qDivorced/Separated qSingle
Medical History: …
Menstrual and Obstetric History (age periods began, normal, abnormal, pregnancies, birth weight and problems): … ……
Present Symptoms (see list on following page and use if required):…..
Excessive tiredness Numbness in:
Pins & needles
Sensitivity to sun
Lack of co-ordination especially of hands and feet
Loss of libido
Repeated urinary tract infections
Upper respiratory tract infections
Pelvic Inflammatory Disease (PID)
Poor response to treatments
Low basal temperature
Mouth & Throat:
Halitosis (bad breath)
Noises in ears (hissing)
Body hair loss
Head hair loss
Eyebrow loss (outer third)
Sallow in colour
Dark rings under eyes
Pigmentation in skin creases
Rashes & dermographia (wheals)
Numbness & Tingling in:
Back and loin pain
Muscle and joint pain
Carpal Tunnel Syndrome
Loss of appetite
Irritable Bowel Syndrome (IBS)
Blood Pressure & Pulse:
High blood pressure
Low blood pressure
Slow/weak pulse (under 60 bpm)
Fast pulse (over 90 bpm at rest)
Cessation of periods (amenorrhoea)
Scanty periods (oligomenorrhoea)
Heavy periods (menorrhagia)
PMS (premenstrual tension)
Memory loss & confusion
Noises and voices in head
Loss of drive
Post Natal Depression
Wanting to be solitary
Feelings of resentment
Lack of confidence
ANY OTHER SYMPTOMS
Name: ……………………………. Date:……………………………
Blood Test History: (Please complete as far as you can. Any results should include reference range.)
Please attach copies of any laboratory tests you have.
Please attach copies of any other laboratory test results, for example, hair analysis, stool analysis etc.
Do You Have Any Yeast or Candida Infections, eg athletes foot, skin rashes, nail infections?
Please Give an Example of Your Daily Diet:
Drinks (including alcohol):
Vitamin & Mineral Supplementation:
Do You Have Any Food Cravings? (please specify)
Which Foods Do You Hate and Therefore Avoid Eating? (NOT due to allergy or intolerance)
Which Particular Food and Drink Do You Consume the Most of Every Single Day?
Are You Aware of Any Food Allergies or Intolerances?
Do You Have Any Intolerances to Medication?
Is There a Family History of Confirmed Diagnosis of: (please tick and specify which relation, eg mother, paternal aunt, maternal grandfather, maternal cousin)
Other (please specify): .
Any Comments About Family History: … .
Have You Been Diagnosed With:
Arthritis q Other
Please Specify: (eg Hashimotos, Hypothyroidism, Lymes Disease).
Date Medical Advice First Sought:(approx)Age:
Date Diagnosed: (approx) Age:..
Date Symptoms Began: (approx)… Age:.
Was Private Advice Sought:
Personal History of Other Illnesses Before Diagnosis: (please give ages where possible)
Glandular Fever q Severe Viral Infection (eg Flu) q Diabetes
Any Other Illnesses: ….. ..
Did You Experience Any Major Life Events Before Diagnosis – Mental or Physical Trauma, Surgery etc: (please give ages where possible)
Any Other Events:………… .
Have You Ever Lived in a Fluoridated Water Supply Area:
Dates: (approx) ….
Have You Had Exposure to Other Environmental Hazards:
Dates/Details: .. .
Have You Experienced Long-term Exposure to Electromagnetic Fields (living near power lines, working with electrical machinery etc):
If you have been diagnosed with Thyroid Disease and/or Low Adrenal Reserve, or been given a trial treatment of Thyroid Hormone and/or Adrenal Support:
Date First Diagnosed: (approx)Age:
Past Average Basal Temperature (if any):
Past Average Basal Pulse Rate (if any): ..
Now Give a History of Your Treatment to Include the Medication and the Dosages.
Now Give Your Present Treatment Including Supplements.
As the following readings are important as an indication of your present metabolic status, would you please ensure you do them. Please take your basal temperature in the morning immediately on waking and before getting out of bed 3 minutes in the mouth. Ladies only do this during your period. Pulse rate bpm number of beats per minute.
Present Average Basal Temperature:(eg 36.5 C)
Day 1 … Day 2 …. Day 3 …. Day 4 …. Day 5 ….
Present Average Basal Pulse Rate: (eg 72 bpm)
Day 1 … Day 2 …. Day 3 …. Day 4 …. Day 5 .
Any Other Comments About Your Past or Present Treatment or Health:.
Dr Barry Durrant-Peatfield MBBS LRCP MRCS Medics Cert. Nutritional Therapy (BCNH)
The Peatfield Clinic
16 Southview Road, Warlingham, Surrey, CR6 9JE
Tel: 01883 623125