Nutritional Assessment Questionnaire Nutritional Assessment Questionnaire – Michelle First NameLast NameToday’s DateDate of BirthGender– Select –FemaleMalePlease list your five major health concerns in order of importancePlease list any diagnoses or known medical issues that you havePlease list all medications (Over the counter or prescription), vitamins, and/or supplements that you takeWhat was the first day of your last period?PreviousNextPart IPlease read the following questions and select the number that applies Key:0 = Do not consume or use1 = Consume or use 2 to 3 times monthly2 = Consume or use weekly3 = Consume or use dailyDiet1. Alcohol 0 1 2 32. Artificial sweeteners 0 1 2 33. Candy, desserts, refined sugars 0 1 2 34. Carbonated beverages 0 1 2 35. Chewing tobacco 0 1 2 36. Cigarettes 0 1 2 37. Cigars/pipes 0 1 2 38. Caffeinated beverages 0 1 2 39. Fast foods 0 1 2 310. Fried foods 0 1 2 311. Luncheon meats 0 1 2 312. Margarine 0 1 2 313. Milk products 0 1 2 314. Radiation exposure (0 = no, 1 = yes) 0 115. Refind flour/baked goods 0 1 2 316. Vitamins and minerals 0 1 2 317. Water distilled 0 1 2 318. Water, tap 0 1 2 319. Water, well 0 1 2 320. Diet often for weight control 0 1 2 3Lifestyle21. Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a month) 0 1 2 322. Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months) 0 1 2 323. Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months) 0 1 2 324. Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always) 0 1 2 3MedicationsIndicate any medications you’re currently taking or have taken in the last month (0 = no, 1 = yes)25. Antacids 0 126. Antianxiety medications 0 127. Antibiotics 0 128. Anticonvulsants 0 129. Antidepressants 0 130. Antifungals 0 131. Aspirin/Ibuprofen 0 132. Asthma inhalers 0 133. Beta blockers 0 134. Birth control pills/implant contraceptives 0 135. Chemotherapy 0 136. Cholesterol lowering medications 0 137. Cortisone/steroids 0 138. Diabetic medications/insulin 0 139. Diuretics 0 140. Estrogen or progesterone (pharmaceutical, prescription) 0 141. Estrogen or progesterone (natural) 0 142. Heart medications 0 143. High blood pressure medications 0 144. Laxatives 0 145. Recreational drugs 0 146. Relaxants/Sleeping pills 0 147. Testosterone (natural or prescription) 0 148. Thyroid medication 0 149. Acetaminophen (Tylenol) 0 150. Ulcer medications 0 151. Sildenafal citrate (Viagra) 0 1PreviousNextPart IIPlease read the following questions and select the number that applies Key:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)Section 1 – Upper Gastrointestinal System52. Belching or gas within one hour after eating 0 1 2 353. Heartburn or acid reflux 0 1 2 354. Bloating within one hour after eating 0 1 2 355. Vegan diet (no dairy, meat, fish or eggs) (0=no, 1=yes) 0 156. Bad breath (halitosis) 0 1 2 357. Loss of taste for meat 0 1 2 358. Sweat has a strong odor 0 1 2 359. Stomach upset by taking vitamins 0 1 2 360. Sense of excess fullness after meals 0 1 2 361. Feel like skipping breakfast 0 1 2 362. Feel better if you don’t eat 0 1 2 363. Sleepy after meals 0 1 2 364. Fingernails chip, peel or break easily 0 1 2 365. Anemia unresponsive to iron 0 1 2 366. Stomach pains or cramps 0 1 2 367. Diarrhea, chronic 0 1 2 368. Diarrhea shortly after meals 0 1 2 369. Black or tarry colored stools 0 1 2 370. Undigested food in stool 0 1 2 3PreviousNextSection 2 – Liver and GallbladderKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)71. Pain between shoulder blades 0 1 2 372. Stomach upset by greasy foods 0 1 2 373. Greasy or shiny stools 0 1 2 374. Nausea 0 1 2 375. Sea, car, airplane or motion sickness 0 1 2 376. History of morning sickness (0 = no, 1 = yes) 0 177. Light or clay colored stools 0 1 2 378. Dry skin, itchy feet or skin peels on feet 0 1 2 379. Headache over eyes 0 1 2 380. Gallbladder attacks (0=never, 1=years ago, 2=within last year, 3=within past 3 months) 0 1 2 381. Gallbladder removed (0=no, 1=yes) 0 182. Bitter taste in mouth, especially after meals 0 1 2 383. Become sick if you were to drink wine (0=no, 1=yes) 0 184. Easily intoxicated if you were to drink wine (0=no, 1=yes) 0 185. Easily hung over if you were to drink wine (0=no, 1=yes) 0 186. Alcohol per week (0=<3, 1=<7, 2 =14) 0 1 2 387. Recovering alcoholic (0=no, 1=yes) 0 188. History of drug or alcohol abuse (0=no, 1=yes) 0 189. History of hepatitis (0=no, 1=yes) 0 190. Long term use of prescription/recreational drugs (0=no, 1=yes) 0 191. Sensitive to chemicals (perfume, cleaning agents, etc.) 0 1 2 392. Sensitive to tobacco smoke 0 1 2 393. Exposure to diesel fumes 0 1 2 394. Pain under right side of rib cage 0 1 2 395. Hemorrhoids or varicose veins 0 1 2 396. Nutrasweet (aspartame) consumption 0 1 2 397. Sensitive to Nutrasweet (aspartame) 0 1 2 398. Chronic fatigue or Fibromyalgia 0 1 2 3PreviousNextSection 3 – Small IntestineKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)99. Food allergies 0 1 2 3100. Abdominal bloating 1 to 2 hours after eating 0 1 2 3101. Specific foods make you tired or bloated (0=no, 1=yes) 0 1102. Pulse speeds after eating 0 1 2 3103. Airborne allergies 0 1 2 3104. Experience hives 0 1 2 3105. Sinus congestion, “stuffy head” 0 1 2 3106. Crave bread or noodles 0 1 2 3107. Alternating constipation and diarrhea 0 1 2 3108. Crohn’s disease (0 =no, 1=yes in the past, 2=currently mild condition, 3=severe) 0 1 2 3109. Wheat or grain sensitivity 0 1 2 3110. Dairy sensitivity 0 1 2 3111. Are there foods you could not give up (0=no, 1=yes) 0 1112. Asthma, sinus infections, stuffy nose 0 1 2 3113. Bizarre vivid dreams, nightmares 0 1 2 3114. Use over-the-counter pain medications 0 1 2 3115. Feel spacey or unreal 0 1 2 3PreviousNextSection 4 – Large IntestineKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)116. Anus itches 0 1 2 3117. Coated tongue 0 1 2 3118. Feel worse in moldy or musty place 0 1 2 3119. Taken antibiotic for a total accumulated time of (0=never, 1= <1 month, 2= 3 months) 0 1 2 3120. Fungus or yeast infections 0 1 2 3121. Ring worm, “jock itch”, “athletes foot”, nail fungus 0 1 2 3122. Yeast symptoms increase with sugar, starch or alcohol 0 1 2 3123. Stools hard or difficult to pass 0 1 2 3124. History of parasites (0=no, 1=yes) 0 1125. Less than one bowel movement per day 0 1 2 3126. Stools have corners or edges, are flat or ribbon shaped 0 1 2 3127. Stools are not well formed (loose) 0 1 2 3128. Irritable bowel or mucus colitis 0 1 2 3129. Blood in stool 0 1 2 3130. Mucus in stool 0 1 2 3131. Excessive foul smelling lower bowel gas 0 1 2 3132. Bad breath or strong body odors 0 1 2 3133. Painful to press along outer sides of thighs (Iliotibial Band) 0 1 2 3134. Cramping in lower abdominal region 0 1 2 3135. Dark circles under eyes 0 1 2 3PreviousNextSection 5 – Mineral NeedsKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)136. History of carpal tunnel syndrome (0=no, 1=yes) 0 1137. History of lower right abdominal pains or ileocecal valve problems (0=no, 1=yes) 0 1138. History of stress fracture (0=no, 1=yes) 0 1139. Bone loss (reduced density on bone scan) 0 1 2 3140. Are you shorter than you used to be? (0=no, 1=yes) 0 1141. Calf, foot or toe cramps at rest 0 1 2 3142. Cold sores, fever blisters or herpes lesions 0 1 2 3143. Frequent fevers 0 1 2 3144. Frequent skin rashes and/or hives 0 1 2 3145. Herniated disc (0=no, 1=yes) 0 1146. Excessively flexible joints, “double jointed” 0 1 2 3147. Joints pop or click 0 1 2 3148. Pain or swelling in joints 0 1 2 3149. Bursitis or tendonitis 0 1 2 3150. History of bone spurs (0=no, 1=yes) 0 1151. Morning stiffness 0 1 2 3152. Nausea with vomiting 0 1 2 3153. Crave chocolate 0 1 2 3154. Feet have a strong odor 0 1 2 3155. History of anemia 0 1 2 3156. Whites of eyes (sclera) blue tinted 0 1 2 3157. Hoarseness 0 1 2 3158. Difficulty swallowing 0 1 2 3159. Lump in throat 0 1 2 3160. Dry mouth, eyes and/or nose 0 1 2 3161. Gag easily 0 1 2 3162. White spots on fingernails 0 1 2 3163. Cuts heal slowly and/or scar easily 0 1 2 3164. Decreased sense of taste or smell 0 1 2 3PreviousNextSection 6 – Essential Fatty AcidsKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)165. Experience pain relief with aspirin (0=no, 1=yes) 0 1166. Crave fatty or greasy foods 0 1 2 3167. Low- or reduced-fat diet (0=never, 1=years ago, 2=within past year, 3=currently) 0 1 2 3168. Tension headaches at base of skull 0 1 2 3169. Headaches when out in the hot sun 0 1 2 3170. Sunburn easily or suffer sun poisoning 0 1 2 3171. Muscles easily fatigued 0 1 2 3172. Dry flaky skin or dandruff 0 1 2 3PreviousNextSection 7 – Sugar HandlingKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)173. Awaken a few hours after falling asleep, hard to get back to sleep 0 1 2 3174. Crave sweets 0 1 2 3175. Binge or uncontrolled eating 0 1 2 3176. Excessive appetite 0 1 2 3177. Crave coffee or sugar in the afternoon 0 1 2 3178. Sleepy in afternoon 0 1 2 3179. Fatigue that is relieved by eating 0 1 2 3180. Headache if meals are skipped or delayed 0 1 2 3181. Irritable before meals 0 1 2 3182. Shaky if meals delayed 0 1 2 3183. Family members with diabetes (0=none, 1=1 or 2, 2=3 or 4, 3=more than 4) 0 1 2 3184. Frequent thirst 0 1 2 3185. Frequent urination 0 1 2 3PreviousNextSection 8 – Vitamin NeedKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)186. Muscles become easily fatigued 0 1 2 3187. Feel exhausted or sore after moderate exercise 0 1 2 3188. Vulnerable to insect bites 0 1 2 3189. Loss of muscle tone, heaviness in arms/legs 0 1 2 3190. Enlarged heart or congestive heart failure 0 1 2 3191. Pulse below 65 per minute (0=no, 1=yes) 0 1192. Ringing in the ears (Tinnitus) 0 1 2 3193. Numbness, tingling or itching in hands and feet 0 1 2 3194. Depressed 0 1 2 3195. Fear of impending doom 0 1 2 3196. Worrier, apprehensive, anxious 0 1 2 3197. Nervous or agitated 0 1 2 3198. Feelings of insecurity 0 1 2 3199. Heart races 0 1 2 3200. Can hear heart beat on pillow at night 0 1 2 3201. Whole body or limb jerk as falling asleep 0 1 2 3202. Night sweats 0 1 2 3203. Restless leg syndrome 0 1 2 3204. Cracks at corner of mouth (Cheilosis) 0 1 2 3205. Fragile skin, easily chaffed, as in shaving 0 1 2 3206. Polyps or warts 0 1 2 3207. MSG sensitivity 0 1 2 3208. Wake up without remembering dreams 0 1 2 3209. Small bumps on back of arms 0 1 2 3210. Strong light at night irritates eyes 0 1 2 3211. Nose bleeds and/or tend to bruise easily 0 1 2 3212. Bleeding gums especially when brushing teeth 0 1 2 3PreviousNextSection 9 – AdrenalKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)213. Tend to be a “night person” 0 1 2 3214. Difficulty falling asleep 0 1 2 3215. Slow starter in the morning 0 1 2 3216. Tend to be keyed up, trouble calming down 0 1 2 3217. Blood pressure above 120/80 0 1 2 3218. Headache after exercising 0 1 2 3219. Feeling wired or jittery after drinking coffee 0 1 2 3220. Clench or grind teeth 0 1 2 3221. Calm on the outside, troubled on the inside 0 1 2 3222. Chronic low back pain, worse with fatigue 0 1 2 3223. Become dizzy when standing up suddenly 0 1 2 3224. Difficulty maintaining manipulative correction 0 1 2 3225. Pain after manipulative correction 0 1 2 3226. Arthritic tendencies 0 1 2 3227. Crave salty foods 0 1 2 3228. Salt foods before tasting 0 1 2 3229. Perspire easily 0 1 2 3230. Chronic fatigue, or get drowsy often 0 1 2 3231. Afternoon yawning 0 1 2 3232. Afternoon headache 0 1 2 3233. Asthma, wheezing or difficulty breathing 0 1 2 3234. Pain on the medial or inner side of the knee 0 1 2 3235. Tendency to sprain ankles or “shin splints” 0 1 2 3236. Tendency to need sunglasses 0 1 2 3237. Allergies and/or hives 0 1 2 3238. Weakness, dizziness 0 1 2 3PreviousNextSection 10 – PituitaryKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)239. Height over 6′ 6″ (0=no, 1=yes) 0 1240. Early sexual development (before age 10) (0=no, 1=yes) 0 1241. Increased libido 0 1 2 3242. Splitting type headache 0 1 2 3243. Memory failing 0 1 2 3244. Tolerate sugar, feel fine when eating sugar (0=no, 1=yes) 0 1245. Height under 4′ 10″ (0=no, 1=yes) 0 1246. Decreased libido 0 1 2 3247. Excessive thirst 0 1 2 3248. Weight gain around hips or waist 0 1 2 3249. Menstrual disorders 0 1 2 3250. Delayed sexual development (after age 13) (0=no, 1=yes) 0 1251. Tendency to ulcers or colitis 0 1 2 3PreviousNextSection 11 – ThyroidKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)252. Sensitive/allergic to iodine 0 1 2 3253. Difficulty gaining weight, even with large appetite 0 1 2 3254. Nervous, emotional, can’t work under pressure 0 1 2 3255. Inward trembling 0 1 2 3256. Flush easily 0 1 2 3257. Fast pulse at rest 0 1 2 3258. Intolerance to high temperatures 0 1 2 3259. Difficulty losing weight 0 1 2 3260. Mentally sluggish, reduced initiative 0 1 2 3261. Easily fatigued, sleepy during the day 0 1 2 3262. Sensitive to cold, poor circulation (cold hands and feet) 0 1 2 3263. Constipation, chronic 0 1 2 3264. Excessive hair loss and/or coarse hair 0 1 2 3265. Morning headaches, wear off during the day 0 1 2 3266. Loss of lateral 1/3 of eyebrow 0 1 2 3267. Seasonal sadness 0 1 2 3PreviousNextSection 12 – Men OnlyKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)268. Prostate problems 0 1 2 3269. Difficulty with urination, dribbling 0 1 2 3270. Difficult to start and stop urine stream 0 1 2 3271. Pain or burning with urination 0 1 2 3272. Waking to urinate at night 0 1 2 3273. Interruption of stream during urination 0 1 2 3274. Pain on inside of legs or heels 0 1 2 3275. Feeling of incomplete bowel evacuation 0 1 2 3276. Decreased sexual function 0 1 2 3PreviousNextSection 13 – Women OnlyKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)277. Depression during periods 0 1 2 3278. Mood swings associated with periods (PMS) 0 1 2 3279. Crave chocolate around periods 0 1 2 3280. Breast tenderness associated with cycle 0 1 2 3281. Excessive menstrual flow 0 1 2 3282. Scanty blood flow during periods 0 1 2 3283. Occasional skipped periods 0 1 2 3284. Variations in menstrual cycles 0 1 2 3285. Endometriosis 0 1 2 3286. Uterine fibroids 0 1 2 3287. Breast fibroids, benign masses 0 1 2 3288. Painful intercourse (dysparenia) 0 1 2 3289. Vaginal discharge 0 1 2 3290. Vaginal dryness 0 1 2 3291. Vaginal itchiness 0 1 2 3292. Gain weight around hips, thighs and buttocks 0 1 2 3293. Excess facial or body hair 0 1 2 3294. Hot flashes 0 1 2 3295. Night sweats (in menopausal females) 0 1 2 3296. Thinning skin 0 1 2 3PreviousNextSection 14 – CardiovascularKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)297. Aware of heavy and/or irregular breathing 0 1 2 3298. Discomfort at high altitudes 0 1 2 3299. “Air hunger” or sigh frequently 0 1 2 3300. Compelled to open windows in a closed room 0 1 2 3301. Shortness of breath with moderate exertion 0 1 2 3302. Ankles swell, especially at end of day 0 1 2 3303. Cough at night 0 1 2 3304. Blush or face turns red for no reason 0 1 2 3305. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion 0 1 2 3306. Muscle cramps with exertion 0 1 2 3PreviousNextSection 15 – Kidney and BladderKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)307. Pain in mid-back region 0 1 2 3308. Puffy around the eyes, dark circles under eyes 0 1 2 3309. History of kidney stones (0=no, 1=yes) 0 1310. Cloudy, bloody or darkened urine 0 1 2 3311. Urine has a strong odor 0 1 2 3PreviousNextSection 16 – Immune systemKey:0 = No, symptom does not occur1 = yes, minor or mild symptom, rarely occurs (monthly)2 = Moderate symptom, occurs occasionally (weekly)3 = Severe symptom, occurs frequently (daily)312. Runny or drippy nose 0 1 2 3313. Catch colds at the beginning of winter 0 1 2 3314. Mucus producing cough 0 1 2 3315. Frequent colds or flu (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year) 0 1 2 3316. Other infections (sinus, ear, lung, skin, bladder, kidney, etc.) (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year) 0 1 2 3317. Never get sick (0 = sick only 1 or 2 times in last 2 years, 1 = not sick in last 2 years, 2 = not sick in last 4 years, 3 = not sick in last 7 years) 0 1 2 3318. Acne (adult) 0 1 2 3319. Itchy skin (Dermatitis) 0 1 2 3320. Cysts, boils, rashes 0 1 2 3321. History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition (0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe) 0 1 2 3 Previous Submit Form
