Health Questionnaire

About you

What's your full name?

Please enter your name.

About you

What's your email address?

Please enter a valid email address.

About you

And a phone number? (optional)

About you

Your age range

Under 25 25–34 35–44 45–54 55–64 65+

About you

Sex assigned at birth

Only used where it matters clinically, e.g. for nutrient needs.

Female Male Prefer not to say

About you

What do you do for work? (optional)

About you

Height, current weight and usual weight (optional)

About you

Any recent weight change you didn’t intend?

Weight gain Weight loss No

About you

Roughly how much, and over what period? (optional)

Your health concerns

What are your three most important health concerns?

Please share at least one concern so Faith knows where to start.

Your health concerns

How long have you had these concerns?

Less than 3 months 3–12 months 1–3 years More than 3 years

Your health concerns

Have you received a diagnosis?

Yes No Under investigation

Your health concerns

What is the diagnosis, or what is being investigated? (optional)

Your health concerns

What have you already tried, and what helped or made things worse? (optional)

Treatments, medications, supplements or lifestyle changes.

Your health concerns

What would you like support with?

Tick all that apply.

Gut health Weight management Energy Blood sugar management Heart health Bloating / constipation Sleep Nutrition habits Liver / kidney health Support with a medical condition Stress management General wellbeing Other

Medical history

Have you ever been diagnosed with or treated for any of these?

Tick all that apply.

Diabetes / prediabetes High or low blood pressure Heart disease High cholesterol Thyroid disorder Liver disease Kidney disease / stones Gastritis / ulcers IBS Inflammatory bowel disease Coeliac disease Reflux Gallbladder disease / gallstones Anaemia Cancer Autoimmune disease Asthma / respiratory disease Food allergy / intolerance Eating disorder history Anxiety / depression Reproductive / hormonal disorder Other None of these

Medical history

When were these diagnosed, how are they treated, and are they under control? (optional)

Medical history

Any previous hospital stays or surgery? (optional)

Medical history

Are you currently under the care of a GP or specialist?

GP Specialist Both No

Medicines & supplements

List every medicine, supplement, vitamin and herb you take (optional)

Include the dose and reason if you know them. Prescription and over-the-counter.

Medicines & supplements

Do you take any of these?

These matter for herbal safety. Tick all that apply.

Blood thinners / antiplatelets Diabetes medication / insulin Blood pressure medication Thyroid medication Psychiatric medication Immunosuppressants Cancer treatments Hormones / contraception Other medicines None of these

Medicines & supplements

Any allergies, or past reactions to herbal products? (optional)

Food, medicine, plants or supplements.

Digestion

Which of these do you get often or daily?

Tick all that apply.

Bloating Constipation Diarrhoea Excessive gas Reflux / heartburn Abdominal pain Nausea Symptoms after certain foods Loss of appetite Feeling full quickly Irregular bowel movements Pain or straining on the toilet None of these

Digestion

How often do you open your bowels?

More than 3 times a day 1–3 times a day Every other day Fewer than 3 times a week

Digestion

What is your stool usually like?

Hard / lumpy Smooth and formed Loose / watery It varies

Digestion

Have you noticed blood in your stool, black stool, persistent vomiting or unexplained weight loss?

Yes No

Digestion

Please give some details, and any medical follow-up so far (optional)

Digestion

Any foods that trigger discomfort? Any recent antibiotics, laxatives or bowel cleanses? (optional)

Food & drink

How many meals do you eat a day?

One Two Three Four or more It’s irregular

Food & drink

How often do you eat fruit and vegetables?

At most meals Daily A few times a week Rarely

Food & drink

Your main protein sources

Tick all that apply.

Fish Poultry Red meat Eggs Beans / legumes Dairy Nuts / seeds Soy products

Food & drink

Which of these do you have most days?

Tick all that apply.

Fresh vegetables Fresh fruit Whole grains White bread, pasta or pastries Beans / legumes Fried foods Sugary snacks Soft drinks Fast food Fermented foods Nuts / seeds Alcohol Coffee, tea or energy drinks

Food & drink

How much water do you drink a day?

Less than 1 litre 1–1.5 litres 1.5–2 litres More than 2 litres Not sure

Food & drink

Which best describes how you eat?

Tick all that apply.

Eat everything Vegetarian Vegan Low carbohydrate Mediterranean-style Intermittent fasting Religious / cultural Medically prescribed diet

Food & drink

Walk us through a typical day of eating and drinking (optional)

Rough amounts are fine. Note any symptoms after meals.

Food & drink

Any cravings, foods you avoid, or things that make eating well hard? (optional)

e.g. health, cultural or religious reasons, cost, time, cooking, appetite.

Energy, sleep & stress

How would you rate your energy?

1 = exhausted, 10 = full of energy

1 2 3 4 5 6 7 8 9 10

Energy, sleep & stress

Do you experience any of these?

Tick all that apply.

Persistent tiredness Afternoon crashes Poor concentration Dizziness Headaches Poor recovery after exercise None of these

Energy, sleep & stress

How many hours do you sleep a night?

Less than 5 5–6 7–8 More than 8

Energy, sleep & stress

How is your sleep quality?

Excellent Good Fair Poor

Energy, sleep & stress

How would you rate your stress?

1 = very calm, 10 = extremely stressed

1 2 3 4 5 6 7 8 9 10

Energy, sleep & stress

What are your main sources of stress, and what helps you relax? (optional)

Lifestyle & environment

How active are you?

Mostly sitting Lightly active Moderately active Very active

Lifestyle & environment

What exercise do you do, and how often? (optional)

Lifestyle & environment

Do you smoke, vape or use nicotine?

Yes No Previously

Lifestyle & environment

How many alcoholic drinks do you have in a week?

None 1–3 4–7 8–14 More than 14

Lifestyle & environment

Do you spend time outdoors regularly?

Yes No

Lifestyle & environment

Are you regularly exposed to any of these, at home or work?

Tick all that apply.

Agricultural pesticides Industrial chemicals Cleaning products / solvents Smoke / indoor air pollution Dust / fumes Dampness / mould Known heavy-metal exposure Possibly unsafe drinking water Other None known

Lifestyle & environment

Where does most of your drinking water come from?

Tap water Filtered tap water Bottled Rainwater Bore / well Other

Women’s health

Are your menstrual cycles regular?

Yes No Not applicable

Women’s health

Do any of these apply to you?

Tick all that apply.

Painful periods Heavy bleeding Irregular cycles Premenstrual symptoms Menopausal symptoms Fertility challenges None of these

Women’s health

Are any of these true right now?

Important for herbal safety. Tick all that apply.

Pregnant Breastfeeding Trying to conceive / fertility treatment Hormonal contraception Hormone therapy (HRT) None of these

Family history

Do any of these run in your immediate family?

Tick all that apply.

Type 2 diabetes High blood pressure Heart disease / stroke Cancer Thyroid disorders Autoimmune disorders Kidney disease Obesity Hereditary disorders None known

Family history

Which conditions, and which relatives? (optional)

Herbal safety

Have you done a herbal cleanse or detox programme before?

Yes No

Herbal safety

Which products or methods, and did you have any side effects? (optional)

Herbal safety

Why are you interested in herbal support?

Tick all that apply.

Digestive comfort Constipation Nutritional support Stress / sleep Metabolic health Support with lifestyle change Environmental concerns Other

Herbal safety

Do any of these apply to you?

Tick all that apply.

Currently fasting Using laxatives or diuretics Following a restrictive diet Doctor-advised limits on fluids, potassium, sodium or protein History of dehydration or fainting History of low blood sugar (hypoglycaemia) History of electrolyte imbalance Diagnosed liver or kidney impairment None of these

Herbal safety

Would you be willing to discuss any suggested herbs with your pharmacist or doctor?

Yes No I’d like more information

Recent tests

Have you had blood tests or other investigations in the past 12 months?

Yes No Not sure

Recent tests

Which tests, and were any results abnormal? (optional)

Also mention any tests your GP has asked for that are still pending. You can bring copies to your consultation.

Your goals

What are your top three goals for the next 12 weeks? (optional)

What would you most like to notice changing?

Your goals

How ready do you feel to make changes?

1 = not yet, 10 = completely ready

1 2 3 4 5 6 7 8 9 10

Your goals

What might make following a plan hard?

Tick all that apply.

Budget Time Family responsibilities Food preferences Work commitments Motivation Medical limitations Other

Your goals

How much time can you spend preparing food each day?

Under 15 minutes 15–30 minutes 30–60 minutes More than an hour

Your goals

Any favourite cuisines, or culturally familiar foods you’d like included? (optional)

And roughly what you spend on food each week, if you’re happy to share.

Your goals

Is there anything else Faith should know? (optional)

Almost done

Check your answers

Tap Edit to change anything.

Declaration & consent

One last step

I confirm the information I’ve given is accurate to the best of my knowledge. I understand that:

• Nutrition and herbal recommendations are individualised and may need coordinating with my treating clinician.
• Herbal products can cause side effects and interact with medicines.
• Completing this questionnaire does not mean herbs are safe or suitable for me.
• I should not stop or change prescribed medication without advice from my prescriber.
• I may decline any recommendation and ask questions before agreeing to it.
• Any proposed approach will be discussed with me separately, including its purpose, benefits, uncertainties, risks and alternatives.

I have read and agree to the above, and consent to Blooms Keen Health using my answers to prepare for my consultation. Type your full name to confirm

Please tick the box and type your name to continue.

Submit questionnaire

We’ll never share your details. Faith will review your answers before your consultation.