1 © CNM 2021

CNM NUTRITION CASE HISTORY FORM (CONFIDENTIAL)

Clinic Details:

Date: …………………………

Clinical Supervisor:…………………………..... Student practitioner:……………………………………….....................

Client’s Details:

Name:…………………………………………............................................................................................................

Date of Birth:…………………........................... Age….................................

Address:

…………………………………………………………………………………………………...........

………….………………………………………………………………………………………...........

Telephone number/s:…………………………………………………………………..........

E-mail address: …………………………………………………………………..............

Sex:…………. Marital Status: ………………… Children:……............

Occupation:……………………………………………………………………………………

Height: ……………………………… Weight: ……………………………..............

Waist circumference: ……............

Referred by:………………………………………………………………….......................

General Practitioner’s Details:

Name: ……………………………………………………………………………................

Address: ………………………………………………………………………………….......

Tel. Number: ………………………………………………………………………………...

Do we have permission to contact your GP if it becomes necessary to do so?

Yes No

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Client copy Terms of Engagement & Consent Form Incl. Case study consent between the CNM naturopathic nutrition student/practitioner and client Good nutrition supports the body’s natural defences and resistance. However, no claim can be made about

the efficacy of any naturopathic nutritional advice.

The naturopathic nutrition student/practitioner

• Naturopathic nutritional advice will be tailored to support medically diagnosed conditions and/or health

concerns agreed and identified by the two parties.

• Naturopathic nutritional practitioners are not permitted to diagnose or claim to treat medical conditions.

• Naturopathic nutritional therapy is not a substitute for professional medical advice and treatment.

The client

• You are responsible for contacting your GP or specialist about any health concerns you may have.

• Please advise your GP of the naturopathic nutrition protocol you will be following. Please also advise any

other complementary medicine practitioners you are consulting.

• It is important that you tell your practitioner about any medical diagnosis you have received any prescription

medication, herbal medicine or food supplements or over the counter medication you are taking as it may

affect the naturopathic nutritional programme.

• If you are unclear about any part of your plan then you should contact your practitioner immediately for

clarification. Your student practitioner will then contact a qualified supervisor to seek advice before

responding to you.

• Your naturopathic nutritional programme and supplement plan will have a time frame and you should not

continue with recommendations outside of this unless agreed by your naturopathic nutritional practitioner.

This is to avoid any adverse reactions.

• Please report any concerns about your programme to your naturopathic nutritional practitioner for

discussion at your next consultation.

We/I understand the above and agree that our professional relationship will be based on the above content of

this document. I consent to the use of a confidential video link to external students and supervisor for

observational purposes only. I understand my case will not be videotaped. I further understand a student

practitioner must have all suggestions authorised by a qualified supervisor. The supervisor may therefore enter

the clinic room at any time. With these understandings, I consent to participating as a client in the student

clinic. I understand that I am being seen for a nutrition consultation either by a student practitioner in his/her

capacity as a final year naturopathic nutrition student, or a qualified supervising practitioner at the College of

Naturopathic Medicine (CNM). I understand that my case may be written up as a case study but that my name

and any personal identifiable details will be removed from the written submission. I understand that this

consent form will be submitted to the College and that I may be contacted for verification.

Further details with regards to how my personal data is processed are available at

https://www.naturopathy-uk.com/about/about-privacy-policy/

I consent to my personal data being used in the manner set out above: □

Signed Agreement

Client Student/professional practitioner

Signature Signature

Date Date

3 © CNM 2021

CNM copy Terms of Engagement & Consent Form Incl. Case study consent between the CNM naturopathic nutrition student/practitioner and client Good nutrition supports the body’s natural defences and resistance. However, no claim can be made about

the efficacy of any naturopathic nutritional advice.

The naturopathic nutrition student/practitioner

• Naturopathic nutritional advice will be tailored to support medically diagnosed conditions and/or health

concerns agreed and identified by the two parties.

• Naturopathic nutritional practitioners are not permitted to diagnose or claim to treat medical conditions.

• Naturopathic nutritional therapy is not a substitute for professional medical advice and treatment.

The client

• You are responsible for contacting your GP or specialist about any health concerns you may have.

• Please advise your GP of the naturopathic nutrition protocol you will be following. Please also advise any

other complementary medicine practitioners you are consulting.

• It is important that you tell your practitioner about any medical diagnosis you have received any prescription

medication, herbal medicine or food supplements or over the counter medication you are taking as it may

affect the naturopathic nutritional programme.

• If you are unclear about any part of your plan then you should contact your practitioner immediately for

clarification. Your student practitioner will then contact a qualified supervisor to seek advice before

responding to you.

• Your naturopathic nutritional programme and supplement plan will have a time frame and you should not

continue with recommendations outside of this unless agreed by your naturopathic nutritional practitioner.

This is to avoid any adverse reactions.

• Please report any concerns about your programme to your naturopathic nutritional practitioner for

discussion at your next consultation.

We/I understand the above and agree that our professional relationship will be based on the above content of

this document. I consent to the use of a confidential video link to external students and supervisor for

observational purposes only. I understand my case will not be videotaped. I further understand a student

practitioner must have all suggestions authorised by a qualified supervisor. The supervisor may therefore enter

the clinic room at any time. With these understandings, I consent to participating as a client in the student

clinic. I understand that I am being seen for a nutrition consultation either by a student practitioner in his/her

capacity as a final year naturopathic nutrition student, or a qualified supervising practitioner at the College of

Naturopathic Medicine (CNM). I understand that my case may be written up as a case study but that my name

and any personal identifiable details will be removed from the written submission. I understand that this

consent form will be submitted to the College and that I may be contacted for verification.

Further details with regards to how my personal data is processed are available at

https://www.naturopathy-uk.com/about/about-privacy-policy/

I consent to my personal data being used in the manner set out above: □

Signed Agreement

Client Student/professional practitioner

Signature Signature

Date Date

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MYMOP2 - Measure Yourself Medical Outcome Profile

Client initials ........................................................................................................................................

Appointment date ................................................... Practitioner seen ....................................................

Choose one or two symptoms (physical or mental) which bother you the most. Write them on the

lines.

Now consider how bad each symptom is, over the last week, and score it by circling your chosen

number.

SYMPTOM 1: ...........................................................................................................................................

0 1 2 3 4 5 6

As good as it could be As bad as it could be

SYMPTOM 2: ...........................................................................................................................................

0 1 2 3 4 5 6

As good as it could be As bad as it could be

Now choose one activity (physical, social or mental) that is important to you, and that your problem

makes difficult or prevents you doing. Score how bad it has been in the last week.

ACTIVITY: .................................................................................................................................................

0 1 2 3 4 5 6

As good as it could be As bad as it could be

Lastly how would you rate your general feeling of wellbeing during the last week?

0 1 2 3 4 5 6

As good as it could be As bad as it could be

How long have you had Symptom 1, either all the time or on and off? Please circle:

0 - 4 weeks 4 - 12 weeks 3 months - 1 year 1 - 5 years over 5 years Are you

taking any medication FOR THIS PROBLEM? Please circle: YES/NO

IF YES:

1. Please write in name of medication, and how much a day/week

..................................................................................................................................................................

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Client’s main aims for consultation Two/three primary goals of the consultation

Presenting symptoms Onset, duration, possible causes, location, sensations, previous treatments, relieving and aggravating factors, progression, concomitants

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Medical history Childhood illnesses, previous accidents, operations or medical interventions, recurrent illnesses or previous diagnoses

Prescription medications- past and present Full name of drug, reason for taking, duration and dosage. Check for OTC medications, oral contraception pill and use of recreational drugs NB – Ensure you have sufficient detail to check for drug nutrient interactions

Natural therapies and supplements Ask about reason for taking, consistency, whether it was prescribed or self-prescribed, dosage and brand. Ask them to bring in

supplements for follow up consultation.

Family History Check for any major diseases in biological family such as CVD, autoimmune disease, diabetes

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Systems review

Gastrointestinal tract Look for symptoms of dysbiosis, disorder or disease - such as reflux, halitosis, bloating, burping, diarrhoea constipation, haemorrhoids,

abdominal pain, urgency, anal pruritis, flatulence, form and frequency of bowel movements (Bristol Stool Chart). Check red flags such as

blood or mucus in stool or any sudden changes in bowel movements. If symptoms are present, ask for relieving and aggravating factors

and relationship of symptoms to food.

Nervous system health Symptoms to investigate: headache/migraine, visual disturbance, dizziness, vertigo, weakness, fainting, fits, tics, parasthesia, mood

changes, emotions, anxiety ,memory and concentration, depression , sleep disturbances, night sweats, vivid or disturbing dreams,

presence and negative effect of stress on health and wellbeing

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Endocrine function (Thyroid, adrenal and blood glucose management) Blood sugar fluctuations and hypo/hyperglycaemia episodes, cravings, frequent urination or excessive thirst, weight gain or loss, presence

of goitre, levels of stress or previous stressful situations. Energy levels and fatigue. You may need to link in previous symptoms already

Reproductive systems (male or female) Fertility history, presence of diagnosed diseases

Females: cycle length, duration, menses, previous pregnancies, STDs, detail of any pre-menstrual symptoms, infections or thrush,

menopause symptoms, libido

Males: any children, libido, fertility, STDs, prostate: frequency of urination, erectile dysfunction

Allergies and immunity

Any known allergies or possible intolerances, wound healing time, atopic diseases such as asthma, eczema, lymphatic congestion,

urticaria, frequent infections, herpes or cold sores. Presence of autoimmune disease.

Respiratory tract Presence of asthma, wheezing, bronchitis, post nasal drip, mucus or sputum, sinusitis, shortness of breath, tonsillitis, ear infections,

persistent cough or dry throat.

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Urinary tract Frequency, urgency, pain, burning, dysuria, haematuria, loin pain, difficulty, colour, smell, presence of UTIs

Cardiovascular system Chest pain, shortness of breath, palpitations, oedema, fainting, varicose veins, cold extremities, check BP, cholesterol levels, CRP, tinnitus

Musculo-skeletal Joint pain, stiffness, joint swelling, back pain, neck pain, injuries, spasms, cramps, recovery from exercise

Skin Acne, dry, oily, eczema, contact dermatitis, psoriasis, rashes, fungal infections, sensitivity, brand of cosmetics/skincare products used,

scalp

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Food intake Cooking habits, budget for food, shopping habits, what is consumed, when and where, any physical reactions observed, and dietary type

e.g. Vegetarian/vegan etc.

Remember to check for: Food cravings, dislikes, foods generally avoided and why, cultural customs. Frequency of fruit, vegetable, dairy, refined foods, gluten products, legumes, animal and vegetarian protein, alcohol consumption, fish

intake, greens, sweets, tinned or frozen foods, take away or pre-packaged meals.

Limits to compliance: preparation time, bringing food to work

Relationship with food

Identify relationship with food, language used such as don’t allow myself certain food, identify forbidden or feared foods, constant yo-

yo dieting and dietary perfectionism. History or current signs of eating disorders such as anorexia, bulimia or binge eating disorders

and general patterns of disordered and overeating seen in obesity (starving and stuffing).

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Physical examination Diagnostic investigations, measurements taken in clinic (waist circumference, waist to hip ratio, BP), zinc taste test, nails, tongue and other

physical observations. Observe weight distribution in obesity e.g. apple/pear shaped.

Lifestyle Work/life balance, type of work, presence of stressors, relaxation, hobbies and interests, exercise type, frequency and duration,

incremental activity, smoking, recreational drug use

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Synopsis

Your synopsis should be the facts you have gathered from the case in readiness to feed back to your supervisor. Please do not interpret at

this point. Your synopsis should include any main points that came up from client’s presenting symptoms plus information ascertained

from dietary analysis.

Red flags: referrals required, medications and your evidence of checking for potential

drug/nutrient/herb interactions

Assessment of current food intake:

H/M/L Protein H/M/L Animal Protein H/M/L Vegetable Protein H/M/L Fish

H/M/L Fats H/M/L Omega 3 H/M/L Omega 6 H/M/L Sat fat H/M/L Trans fats

H/M/L Carbohydrates H/M/L Complex H/M/L Simple H/M/L Grains

H/M/L Vegetable intake H/M/L Fruit intake H/M/L Greens

Other important points about the diet:

Assessment of nutritional needs:

Potential macro/micronutrient insufficiencies seen through diet/symptoms/increased needs:

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Naturopathic Summary

Case interpretation/naturopathic hypothesis: Identify antecedents (genetic or constitutional factors), triggers and drivers (mediators)

with evidence from the synopsis. Identify systems indicated for support .Be sure to focus on the areas of assimilation, defence and repair,

energy production, biotransformation and elimination, transport, communication and structural integrity. Also think about the mental,

emotional and physical balance.

Functional testing required for investigation of root causes/mediators (these must be justified on merit)

Therapeutic aims Try to limit your aims, rank them in order of importance and divide them in to short and long term goals. Keep them as objective and

measurable as possible. Your aims are about what you would like to see change in the drivers you discovered in the summary.