Pre-consultation questionnaire
Please fill in as much as you can below to aid me in assessing your needs:
Date:
Contact details
Your details – as my key contact person:
1a) Name:
1b) Address:
1c) Email address:
1d) Phone number(s): .
* Every usual precaution is taken to keep your emails and correspondence secure and confidential – my account and laptops are password protected and only accessed by me. With any system, there is always a small risk of emails going astray or accounts being hacked. As we may be exchanging sensitive information about health, please confirm that you consent to us corresponding by email: Yes / No
NB: If this is something you are concerned about, for additional security, documents like this one, containing sensitive information can be password protected before sending them – just let me know the password to open it in a separate call or email.
For parents/carers: Please enter the rest of the form about your child/the person you are caring for:
2a) Name: Your relationship to this child/person:
2b) Date of Birth:
2c) GP name and address:
2d) GP phone number:
*As standard professional courtesy and best practice I will correspond with your GP to let them know I am advising you, and to ask them to share any relevant information from your history. By having a consultation with me you are consenting to this – please discuss with me if you don’t want this to happen.
2e) Please list names, addresses and phone numbers of other relevant professionals involved who I will copy into contact with your GP: e.g. consultants, health visitors, practice nurses, dietitians, nutritionists:
3) How did you hear about my services?:
Current issue:
4a) What are your reasons for contacting me – what are your current diet-related issues or worries?
4b) In an ideal world, what would you like to come out of consultations with me?
Medical history:
5a) How would you score your current state of health on a scale of 1-10 with 10 being great, and 1 being poor:
5b) Current diagnoses and/or medical problems and rough date they started:
5c) Past medical problems that are now resolved, and rough dates of when they started and resolved:
5d) Current medications and how often you take them:
5e) Are you awaiting any medical tests or results or operations? Give details:
5f) Any bowel problems not stated above – such as constipation, wind, diarrhoea, etc:
Please enclose any key medical reports, or bring them with you to your consultation
Medical nutrition history:
6a) Known food allergies/intolerances, and for each, what was the worst reaction to this food, and roughly when:
6b) Results of any previous allergy tests via the NHS:
6c) Have you ever been tested for Coeliac disease? Please give details:
6d) Do you have or have you ever had nasogastric (NG), gastrostomy or other tube feeds? If yes – please give details?
6e) Do you have, or have you ever had any nutritional deficiencies e.g. iron-deficiency? Please give details.
6f) Are you taking any prescribed nutritional supplements e.g. iron, calcium; or medical nutrition products e.g. Ensure, Fortisip, Scandishake, Calogen, Paediasure, etc – please give details:
6g) Have you ever been told your weight or growth is of concern – please give details:
6h) Recent weight and height if relevant:
Social and psychological issues:
7a) Who else do you live with?
7b) Profession/job/studies and rough hours worked:
Or: hours attending school or nursery?
7c) Do you /did you receive any special education support?
7d) Are there any social or psychological issues I should know about, e.g. recent traumas or upheavals?
Current Diet
8a) What dietary problems do you have and when did they start?
8b) What do you think the reasons for the dietary problems are?
8c) Have you seen a dietitian or nutritionist before?
If so, when, and what was the advice given?
What advice was helpful?
8d) Do any other members of your family have any dietary issues? Give details:
8e) What are your preferred foods and drinks?
8f) What foods and drinks won’t you or don’t you eat/drink?
8g) What do you think of your current diet? Do you think you eat healthily? What do you think you could improve?
Please enclose a diet diary, or bring it with you to your consultation
9) Is there anything else you want to tell me:
NB) Part of my work involves educating dietitians and other health professions and raising awareness of dietary issues in general. I do this via education sessions, writing chapters for books, and writing on my website. Case studies are a really useful learning tool. Would you give your permission for me to use your case as a completely anonymous case study in these ways?
---Thankyou---
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