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:

qExcessive tiredness Numbness in:

qWeight gain

qWeight loss

qCold extremities

qCold sweats

qNight sweats

qSlow movements

qSlow speech

qPins & needles

qBreathlessness

qDizziness
qPalpitations
qSensitivity to sun
qLack of co-ordination especially of

hands and feet

qTrembling

qInsomnia

qLoss of libido

qRepeated urinary tract infections

qUpper respiratory tract infections

qPelvic Inflammatory Disease (PID)

qPoor response to treatments

qCandida

qHeavy eyelids

qHoarse voice

qGoitre

qMuscle cramps

qJoint stiffness

qHeat/Cold intolerance

qLow basal temperature

qExercise intolerance

qSalt craving

qSweet craving

qHypoglycaemia

qFainting attacks

qAsthma

qInternal shivering

Puffiness of:

qEyes

qFace

qHands

qFeet

qAnkles

Mouth & Throat:

qDifficulty swallowing

qSore throats

qSwollen tongue

qChoking fits

qDry mouth

qHalitosis (bad breath)

Hearing Problems:

qOversensitive hearing

qNoises in ears (hissing)

qDeafness

Hair:

qBody hair loss

qHead hair loss

qBrittle hair

qEyebrow loss (outer third)

qEyelash loss

Nails:

qBrittleness

qFlaking

Skin:

qDry

qFlaky

qCoarse patches

qSallow in colour

qPallor

qDark rings under eyes

qPigmentation in skin creases

qRashes & dermographia (wheals)

Numbness & Tingling in:

qLegs

qFeet

qArms

qHands

qBack

q Face

Pain:

qMigraines

qPressure headaches

qBack and loin pain

qWrist pain

qMuscle and joint pain

qCarpal Tunnel Syndrome

Digestive Problems:

qLoss of appetite

qFood allergy/sensitivity

qAlcohol intolerance

qConstipation

qHaemorrhoids

qIrritable Bowel Syndrome (IBS)

qAbdominal distension/flatulence

Blood Pressure & Pulse:
qHigh blood pressure
qLow blood pressure

qSlow/weak pulse (under 60 bpm)

q Fast pulse (over 90 bpm at rest)

Menstrual disorders:

qCessation of periods (amenorrhoea)

qScanty periods (oligomenorrhoea)

qHeavy periods (menorrhagia)

qInfertility

qPMS (premenstrual tension)

Visual disturbances:

qPoor focussing

qDouble vision

qDry eyes

qGritty eyes

qBlurred vision

MENTAL

qPanic attacks

qMemory loss & confusion

qMental sluggishness

qPoor concentration

qNoises and voices in head

qHallucinations

qPhobias

qLoss of drive

qPost Natal Depression

qNightmares

EMOTIONAL

qEasily upset

qWanting to be solitary

qMood swings

qDepression

qNervousness/anxiety

qPersonality changes

qFeelings of resentment

qLack 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)

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

Reasons/Details: …

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: ……

..

Details/Comments:………

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:……..

……

Details/Comments:……..

Have You Ever Lived in a Fluoridated Water Supply Area: q Yes q No
Dates: (approx) ….

Districts: ….

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

.

.

Have You Experienced Long-term Exposure to Electromagnetic Fields (living near power lines, working with electrical machinery etc): q Yes q 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.

…

.

.

.

.

.

..

…

.

.

.

.

.

.

.

.

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