Naturopathic Health History Investigation

To be filled by the client or consultant
Part 2 of 2

Visit us at: www.nutrition2heal.me

15- Liquid intake review 16- Food preparation / methods 17- Lifestyle 18- Face examination 19- Nail Examination 20- Tongue Examination 21- Gum Examination 22- Eye Examination 23- Hair Examination 24- Urine Examination 25- Bristol Stool Chart 26- Stool Type and colour 27- Testing potential hydrogen, pH 28- Physical work condition

Client's Name:

Address:

15- Liquid intake review

Alcohol

Caffeine

Herbal teas

Juices

Sugary drinks

Water

Please write details of your liquid intake in this box:
16- Food preparation / methods

Any limits to compliance

Batch cooking

Budget for food

Cooking habits

Preparation methods

Recipes’ support

Shopping habits

Please write details of your Food preparation / methods in this box:
17- Lifestyle

Exercise type

Frequency and duration

Hobbies and interests

Incremental activity

Recreational drug use

Smoking

Type of work

Ways to unwind

Work / life balance

Please write details of your Lifestyle in this box:

18- Face examination

If any below face signs/symptoms exist, please check them or write in the box. Alternatively, send a picture to: nutrition2heal.me@nutrition2heal.me

Strong red

Pale red or malar flush

Pallor

Yellow, puffy

Dry

Lines across the forehead

Lines between eyebrows

Lines above lips

Dry lips

Brown shadows under eyes

Blue/black shadows under eyes

Lip angular stomatitis / cheilitis

Inelastic skin

Dermatitis (nasolabial, eyelids, in ears)

Hyperpigmentation of mouth, cheek and eye areas

Please write details of your Face examination in this box:
19- Nail Examination

Write full details below. Some terms explained: click please. Send pictures to: nutrition2heal.me@nutrition2heal.me

White nails

White paint-like spots

Absent lunula

Pyramidal lunula

Pale blue lunula

Red lunula

Terry’s nails

Thin, brittle nails

Paronychia

Wicks (or hangnails)

Clubbing

Koilonychia

Beau’s Lines

Longitudinal ridges

Central ridges

Nail pitting

Nail thickening

Nail beading

Onycholysis

Please write details of your Nail examination in this box:
20- Tongue Examination

Clients can send a picture of their tongue if they so wish to: nutrition2heal.me@nutrition2heal.me

Pale

Red purple

Red papillae

Excess papillae

Dry and cracked

Wet

Thin Tongue

Swollen

Scalloped

Rased / upturned edges

Tremor / quiver

Medial fissure/crack

Midline fissure at the tip

Geographical (mapped) tongue

Thin white coat

Brown Coat

Greasy yellow coat

No Coat

Please write details of your Tongue examination in this box:
21- Gum Examination

Bleeding

Periodontal disease

Pale mucous membranes

Greyish mucous membranes

Please write details of your gum examination in this box:
22- Eye Examination

Clients can send a picture of their eyes if they wish so to: nutrition2heal.me@nutrition2heal.me

Contracted pupil

Dilated pupil

Dry eyes

Night blindness

Pale conjunctiva

Blue sclera

Photophobia

Lack of eyelashes and eyebrows

Please write details of your Eye examination in this box:
23- Hair Examination

1- Hair loss

2- Brittle

3- Dry

4- Lacklustre

Please write details of your hair examination in this box:
24- Urine Examination

1- Pale yellow / colourless

2- Dark yellow/strong smelling

3- Very dark yellow, orange or brown

4- Blood in urine: Red flag

5- Unpleasant smelling / cloudy urine

Foods change urine colour without harm:
Beetroot: red. | Asparagus: green/smelly. | Blackberries: red/brown. | Vitamin B2: bright neon yellow.
It takes 24-28 hours for colour to return to normal.
Click here for urine test and pH details.
Please write details of your urine examination in this box:
25- Bristol Stool Chart

Please Click here to see the Bristol Stool Chart. Put the number similar to your stool below:
Bristol Stool Chart Number:
26- Stool Type and colour

Thin stools

Floating stool

Sinking stool

Dry stools

Infrequent stools

Very pale / clay colour stools

Green stools

White mucous in stools

Very dark brown stools

Orange coloured stool

Black tarry stools

Blood in stools

Please write details of your Stool Type and colour in this box:
27- Testing potential hydrogen, pH

Numerical scale measuring acidity/alkalinity. Click here for details on saliva pH test.
pH Number:
28- Physical work condition

Please explain physical condition of your work (sitting, driving, walking, etc.):

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