LIFESTYLE CONSULTATION

Medical Symptom Questionnaire

More details about you to better tailor your consultation session

Medical Symptom Questionaire
Name
Name
First
Last

Rate each of the following symptoms based on your typical health for the last 14 days

POINT SCALE:

0 – Never or almost never have the symptom     1 – Occasionally have it, effect is not severe     2 – Occasionally have it, effect is severe     3 – Frequently have it, effect is not severe     4 – Frequently have it, effect is severe

Head

Headaches:

Faintness:

Dizziness:

Insomnia:

Nose

Stuffy nose:

Sinus problems:

Hay fever:

Sneezing attacks:

Excessive mucus formation:

Eyes

Watery or itchy eyes:

Swollen, reddened, or sticky eyelids:

Bags or dark circles under eyes:

Blurred or tunnel vision:
(does not include near or far-sightedness)

Mouth / Throat

Chronic coughing:

Gagging, frequent need to clear throat:

Sore throat, hoarseness, loss of voice:

Swollen or discoloured tongue, gums, lips:

Canker sores:

Ears

Itchy ears:

Earaches, ear infections:

Drainage from ears:

Ringing in ears, hearing loss:

Skin

Acne:

Hives, rashes, dry skin:

Hair loss:

Flushing, hot flushes:

Excessive seating:

Heart

Irregular or skipped heartbeat:

Rapid or pounding heartbeat:

Chest pain:

Lungs

Chest congestion:

Asthma, bronchitis:

Shortness of breath:

Difficulty breathing:

Digestive tract

Nausea, vomiting:

Diarrhea:

Constipation:

Bloated feeling:

Belching, passing gas:

Heartburn:

Intestinal/stomach pain:

Joints / Muscles

Pains or aches in joints:

Arthritis:

Stiffness or limitation of movement:

Pains or aches in muscles:

Feeling of weakness or tiredness:

Weight

Binge eating/drinking:

Craving certain foods:

Excessive weight gain or loss:

Compulsive eating:

Water retention:

Under weight:

Energy / Activity

Fatigue, sluggishness:

Apathy, lethargy:

Hyperactivity:

Restlessness:

Mind

Poor memory:

Confusion, poor comprehension:

Poor concentration:

Poor physical coordination:
Difficulty in making decisions:

Stuttering or stammering:

Learning disabilities:

Slurred speech:

Emotions

Mood swings:

Anxiety, fear, nervousness:

Anger, irritability, agressiveness:

Depression:

Other

Frequent illness:

Frequent or urgent urination:

Genital itch or discharge:

Proud Member Of

Meet Your Practitioner, Shelly

Foundational & Functional Medicine Practitioner, Nutritional Therapist, Trainer & Educator

Hi, I’m Shelly.

I specialise in natural, root-cause health solutions that focus on supporting the body rather than masking symptoms.

What this means for you:

  • Root-cause, foundational approach to natural health

  • Focus on cellular health, detox pathways, and balance

  • Science-informed, holistic strategies for lasting results

  • Personalised guidance tailored to your health goals

3-Step Approach to Restoring Health Naturally

We deliver lasting health improvements by addressing the root causes of imbalance, not just the symptoms.

Step 1 - Discover The Root Cause

We begin by identifying what’s really going on beneath the surface.

Through a detailed consultation, health history, and testing (if needed), I look beyond symptoms to uncover the underlying imbalances, toxins, or deficiencies affecting your wellbeing.

Step 2 - Create a Personalised Plan

Once we understand your body’s unique needs, I design a bespoke programme focused on detoxification, targeted supplementation, nutrition, and lifestyle guidance.

Every plan is tailored to support your healing process and fit naturally into your daily life.

Step 3 - Restore & Maintain Balance

Healing is a journey not a quick fix. I’ll guide you with ongoing support, education, and adjustments as your body restores balance and vitality.

Together, we’ll create long-term changes that lead to lasting health and a renewed sense of wellbeing.

Ready To Give Your Health A New Lift?