Jump Start Body Scan

Name Address Phone

Angelica Scamardella

Gender

Galley Hill, Hemel Hempstead, HP1 3RE 07594 159 552

Email

scamardella51@aol.com

Age

34

Ethnicity White european

Do you have any chronic health issues/conditions that you have learnt to live with?

Asthma

Do you have chronic pain?

no

Please tick any condition that you regularly experience

Mind Cant switch off Difficult make decisions Difficulty concentrating Difficulty learning new things Dyslexia Dyspraxia Easily confused Easily distracted Easily frustrated Fogginess Forgetful Hyperactive Loss of interest in daily life No motivation Panic attacks Brittle Dandruff Decreased body hair Dry Increased body hair Increased facial hair Oily Poor condition Prematurely grey Thinning Ears Blocked Creased earlobe Itchy Overly waxy Sore Watery Weeping Hair Genitals Cystitis Groin pain Herpes Impotence Itchy Painful intercourse Painful or frequent urination Pelvic inflammatory disease Prostatitis Thrush Ulcers Unexplained discharge Vaginal dryness Warts Skin prone to Acne Allergic reactions Boils Cellulite Dermatitis Easy bruising Eczema Excessive sweating Hives Itching Pimples Psoriasis Rashes Ringworm Rosacea Stretch marks Thread veins Varicose veins

Mood (please tick the boxes for predominant- even if they conflict) Aggressive Agitated Angry Annoyed Anxious Balanced Cant be bothered Cheerful Depressed Easily upset Explosive Fluctuating Frightened Happy Hyperactive Jittery Optimistic Overwhelmed Pent up Pessimistic Sad Suicidal Tearful Tense Tired Worried Muscles Cramps Frozen Loss of tone Numbness Restless legs Sore Spasms Stiff Tender Twitches Wasting Weak Head Dizziness Feeling of hangover Fuzzy headed Headaches Migraine Poor balance Pounding head Stiff neck Unexpected pain

Nose Congested Frequent nose bleeds Hay fever Poor sense of smell Post-nasal drip Prone to snoring Rhinitis Runny Sinusitis Sneezing Stuffy Joints (fingers, knees, back, shoulders, Ect.) Arthritic Difficulty bending Inflamed Painful Reduced mobility Rheumatic Slow movement Sore Stiff Swollen Unsteadiness Hands Chilblains Cold Cracked Dry Eczema Feel clumsy & uncoordinated Numbness Poor circulation Puffy Sore joints Tingling Skin Brown patches Change in moles or lesions Clammy Congested Dry Flaky Oily Pale Prematurely lined Puffy Rough Scaly Yellow

Legs & feet Aching Athletes foot Burning feet Cold feet Fungal nails Gout Numb Prickling Restless legs Sciatica Swollen Tender heels Tingling Mouth Bad breath Bleeding gums Cold sores Difficult swallowing Dry mouth Excess saliva Gingivitis Hoarse voice Mouth ulcers Poor sense of taste Sore throat Sore tongue Tooth decay Gut Acid reflux Belching Bloated Churning Coeliac Constipation Cramping Diarrhoea Distended Flatulence Haemorrhoids Heart burn Hiatus hernia Irritable bowel syndrome Nausea Painful Polyps Sensation of fullness Sensitivity Sluggish Tender Ulcers Bags

Chest Asthma Bronchitis Chest discomfort/ pain Chest infection Diagnosed heart condition Difficulty breathing Noisy breathing Palpitations Persistent cough Request colds Short of breath Wheezing Nails Brittle Dark nails Dry Flaky Fragile Horizontal white line Infected Pale nail bed Peeling Ridged Split cuticles Splitting Spoon shaped Thickened White spots on 2 or more nails Eyes Blurred vision Burning Cataracts Double vision Dry Failing eyesight Gritty Itchy Painful Poor night vision Prone to infection Protruding Sensitive to light Sticky Swollen eyelids Yellowish

Medical conditions Medication Food allergies

Asthma

inhalers

What is your activity level at work/study/spare time?

Low physical activity Heavy physical activity

Moderate physical activity Vigorous activity

How many hours of sleep do you get per night on average? Do you smoke?

When do you typically go to 12 bed? How many cigarettes a day? 10

yes

Weekday 1

Weekday 2

Day off

coffee

coffee

coffee coffee

Breakfast

ham and cheese sandwich

Lunch

ham and cheese sandwich

toast or salad or plain pasta with some Parmesan cheese

Dinner

Pasta and peas baked potatoes with pan fried chicken breast Steamed peas then add with olives, capers and olive oil, garlic and fresh tomatoes, cook spring onion + for couple of min then tomatoes salad add the pasta and parmesan cheese

usually weekends we have a bbq. rarely I will have a burger, usually is chicken breast + salad and roast pepers

no
Snacks

no

weekends i will have a home made cheese pie ( curd cheese with eggs, sugar and raisins) or a cherry pie.

2 Coffees (2 sugar/cup)

2 Coffees (2 sugar/cup)

2 Coffees (2 sugar/cup)

Teas (

sugar/cup)

Teas (

sugar/cup) sugar/cup)

Teas (

sugar/cup) sugar/cup)

Green teas ( sugar/cup) 1 Herbal/fruit teas (1 sugar/cup) Fizzy drinks

Green teas (

Green teas (

1 Herbal/fruit teas (1 sugar/cup) Fizzy drinks

1 Herbal/fruit teas (1 sugar/cup) 1-2 Fizzy drinks

Drinks

Squash Bought juices Homemade juices or smoothies Alcohol

someWater

Squash Bought juices Homemade juices or smoothies Alcohol

someWater

Squash Bought juices Homemade juices or smoothies 1-2 Alcohol

someWater

Other

Other

Other