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):…..
qExcessive tiredness Numbness in:
qPins & needles
qSensitivity to sun
qLack of co-ordination especially of
hands and feet
qLoss of libido
qRepeated urinary tract infections
qUpper respiratory tract infections
qPelvic Inflammatory Disease (PID)
qPoor response to treatments
qLow basal temperature
Mouth & Throat:
qHalitosis (bad breath)
qNoises in ears (hissing)
qBody hair loss
qHead hair loss
qEyebrow loss (outer third)
qSallow in colour
qDark rings under eyes
qPigmentation in skin creases
qRashes & dermographia (wheals)
Numbness & Tingling in:
qBack and loin pain
qMuscle and joint pain
qCarpal Tunnel Syndrome
qLoss of appetite
qIrritable Bowel Syndrome (IBS)
Blood Pressure & Pulse:
qHigh blood pressure
qLow blood pressure
qSlow/weak pulse (under 60 bpm)
q Fast pulse (over 90 bpm at rest)
qCessation of periods (amenorrhoea)
qScanty periods (oligomenorrhoea)
qHeavy periods (menorrhagia)
qPMS (premenstrual tension)
qMemory loss & confusion
qNoises and voices in head
qLoss of drive
qPost Natal Depression
qWanting to be solitary
qFeelings of resentment
qLack of confidence
ANY OTHER SYMPTOMS
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)
q Thyroid Disease q ME/CFS . q Fibromyalgia q Autoimmune Disease q Diabetes q Arthritis q Heart Disease/Stroke q Mental Illness
q Other (please specify): .
Any Comments About Family History: …
Have You Been Diagnosed With:
q Thyroid Disease q ME/CFS q Fibromyalgia q Autoimmune Disease
q Diabetes q Heart Disease/Stroke q Mental Illness q 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: q Yes q No
Personal History of Other Illnesses Before Diagnosis: (please give ages where possible)
q 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)
q Hysterectomy q Neck Injury/Whiplash q Tonsillectomy q Cholecystectomy q Traumatic Pregnancy/Birth q Severe Accident q Divorce q Bereavement
Any Other Events:……..
Have You Ever Lived in a Fluoridated Water Supply Area: q Yes q No
Dates: (approx) ….
Have You Had Exposure to Other Environmental Hazards: q Yes q No
Have You Experienced Long-term Exposure to Electromagnetic Fields (living near power lines, working with electrical machinery etc): q Yes q No
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