This website is dedicated to the millions of thyroid patients who are being ignored and left to suffer unnecessarily, and to healthcare practitioners, who want to better serve those patients.

Dr Peatfield’s Questionnaire

The Peatfield Clinic Metabolic Health Questionnaire

Name: .

Address:

Telephone Number: Mobile No:

Email:

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

Occupation:

Hobbies:..

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):…..
…….

SYMPTOMS LIST

PHYSICAL

General:
Excessive tiredness Numbness in:
Weight gain
Weight loss
Cold extremities
Cold sweats
Night sweats
Slow movements
Slow speech
Pins & needles
Breathlessness
Dizziness
Palpitations

Sensitivity to sun
Lack of co-ordination especially of hands and feet
Trembling
Insomnia
Loss of libido
Repeated urinary tract infections
Upper respiratory tract infections
Pelvic Inflammatory Disease (PID)
Poor response to treatments
Candida
Heavy eyelids
Hoarse voice
Goitre
Muscle cramps
Joint stiffness
Heat/Cold intolerance
Low basal temperature
Exercise intolerance
Salt craving
Sweet craving
Hypoglycaemia
Fainting attacks
Asthma
Internal shivering

Puffiness of:
Eyes
Face
Hands
Feet
Ankles

Mouth & Throat:
Difficulty swallowing
Sore throats
Swollen tongue
Choking fits
Dry mouth
Halitosis (bad breath)

Hearing Problems:
Oversensitive hearing
Noises in ears (hissing)
Deafness

Hair:
Body hair loss
Head hair loss
Brittle hair
Eyebrow loss (outer third)
Eyelash loss

Nails:
Brittleness
Flaking

Skin:
Dry
Flaky
Coarse patches
Sallow in colour
Pallor
Dark rings under eyes
Pigmentation in skin creases
Rashes & dermographia (wheals)

Numbness & Tingling in:
Legs
Feet
Arms
Hands
Back
Face

Pain:
Migraines
Pressure headaches
Back and loin pain
Wrist pain
Muscle and joint pain
Carpal Tunnel Syndrome

Digestive Problems:
Loss of appetite
Food allergy/sensitivity
Alcohol intolerance
Constipation
Haemorrhoids
Irritable Bowel Syndrome (IBS)
Abdominal distension/flatulence

Blood Pressure & Pulse:
High blood pressure
Low blood pressure
Slow/weak pulse (under 60 bpm)
Fast pulse (over 90 bpm at rest)

Menstrual disorders:
Cessation of periods (amenorrhoea)
Scanty periods (oligomenorrhoea)
Heavy periods (menorrhagia)
Infertility
PMS (premenstrual tension)

Visual disturbances:
Poor focussing
Double vision
Dry eyes
Gritty eyes
Blurred vision

MENTAL
Panic attacks
Memory loss & confusion
Mental sluggishness
Poor concentration
Noises and voices in head
Hallucinations
Phobias
Loss of drive
Post Natal Depression
Nightmares

EMOTIONAL
Easily upset
Wanting to be solitary
Mood swings
Depression
Nervousness/anxiety
Personality changes
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.

TEST
Date

Result

Reference Range

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:

Breakfast:

Lunch:

Dinner:

Snacks:

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)

Thyroid Disease
ME/CFS .
Fibromyalgia
Autoimmune Disease
Diabetes

Arthritis
eart Disease/Stroke

Mental Illness

Other (please specify): .

Any Comments About Family History: … .
. ….

Have You Been Diagnosed With:

Thyroid Disease
ME/CFS
Fibromyalgia
Autoimmune Disease
Diabetes
Heart Disease/Stroke
Mental Illness
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:
Yes
No

Reasons/Details: .

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: ….. ..

Details/Comments:………

Did You Experience Any Major Life Events Before Diagnosis – Mental or Physical Trauma, Surgery etc: (please give ages where possible)

Hysterectomy
Neck Injury/Whiplash
Tonsillectomy
Cholecystectomy
Traumatic Pregnancy/Birth
Severe Accident
Divorce
Bereavement

Any Other Events:………… .

Details/Comments:……

Have You Ever Lived in a Fluoridated Water Supply Area:
Yes
No

Dates: (approx) ….

Districts: ….

Have You Had Exposure to Other Environmental Hazards:
Yes
No
Dates/Details: .. .
.

Have You Experienced Long-term Exposure to Electromagnetic Fields (living near power lines, working with electrical machinery etc):
Yes
No

Dates/Details:.. .
..

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.

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Now Give Your Present Treatment Including Supplements.

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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:.

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…..

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

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