Please copy this page and paste it in a reply to our most recent email thread. Fill in your answers and return to me at least 48 hours before your next appointment. Thank you!
If you are working from a phone or tablet and can’t select the whole questionnaire to print try selecting the last word of the questionnaire and then scanning upwards – sometimes this works better!
Alongside ongoing work. what do you want to work on specifically right now?
Are there any conditions that you are being treated for since your last appointment? Please outline any medication or treatment:
Please score how you have felt in the following areas over the last two to three days. Note that the scale is different for each area! Choose just a single number score for each area but feel free to add any extra details. These scores are partly to focus yourself on what has been going on for you lately, and partly to act as a prompt sheet for me so that we don’t miss any relevant health changes or concerns in your appointment.
No Energy = 0 – 15 = High Energy
Your energy score:
Poor Sleep = 0 – 10 = Deep, refreshing sleep
Your sleep score:
Mostly angry or sad = 0 – 15 = Mostly happy and connected
Your mood score:
Dull, dry or spotty; eczema or psoriasis = 0 – 10 = Clear, supple skin
Your skin score:
Frequent, severe, lasting or migraines = 0 – 10 = None or very rare headaches
Your headache score:
Heartburn, constipation, diarrhoea, cramps = 0 – 15 = Smooth, efficient
Your digestion score:
Unable to cope with external stress = 0 – 10 = Easily deal with stressful situations
Your stress score:
Frequent pain or dripping nose = 0 – 5 = No sinus issues
Your sinus score:
High and/or constant level = 0 – 10 = no current pain other than a recent accident
Your pain score:
Add your individual scores up to get your total score _____/100
Please tell me here if there is anything you wish to tell me about your previous cycles:
Please tell me if there is anything you wish to tell me about current perimenopausal or menopausal symptoms:
Since your last appointment
Have any new concerns appeared?
Have any existing concerns been resolved?
Are there any of my last recommendations that you have found difficult? Can you tell me why?
Are there any of my last recommendations that you have found particularly helpful?
Food and Drink Diary
Please also provide me with a recent and detailed three day food and drink diary.
It is useful for me to know details such as how much water you drank each day, whether food is organic, whether it is homemade, what kind of oils or fats you used, how much sugar you took in a drink, whether your meal or snack left you tired, overstuffed or still hungry; and whether you ate from hunger, habit, boredom craving or other emotion.
Include any supplements you currently take: