Health & Wellbeing Questionnaire

Well Person Screening Questionnaire to be completed by the client following confirmation of your booked appointment.

Medical History

1. Have you, or are you, suffering from any serious illness / medical conditions? Yes No

If Yes’ please provide further details:

2. Are you taking medication prescribed by your doctor? Yes No

If Yes’ please provide further details:

3. Is there a history in your immediate family of: Please tick the relevant boxes

Diet Day One

Please make a list of the foods you have eaten in the past two days including hot and cold drinks and beverages containing alcohol.

Diet Day Two

Alcohol

Do you know how much you really drink?

Women: should drink no more than 14 units of alcohol per week, these units should be spread out through the week and they should have at least two alcohol-free days a week. Men: should drink no more than 14 units of alcohol per week, these units should be spread out through the week and they should have at least two alcohol-free days a week. Binge drinking - six or more standard drinks in one sitting can significantly increase the risk of developing physical health issues including liver disease, cancer and high blood pressure. Alcohol is also a depressant and can have serious negative mental health effects.

1 Unit is equal to

Half a pint ordinary beer, lager or cider

One single measure of spirits, Whisky, Gin, Bacardi and Vodka

One small glass of wine

One small glass of sherry

One measure of vermouth or aperitif

Please note: Extra strong lager, etc. contains almost three times as much alcohol as ordinary beer.

Alcohol Diary For Last Week

Smoking

Please tick and complete the following:

Smoking Status

Exercise

Exercise plays an important part in your overall wellbeing.

It helps most of the system and organs in your body to work better. It also helps you feel more energised. The more you do, the easier it gets.