Nutritional Assessment Questionnaire

Nutritional Assessment Questionnaire – Michelle

First Name

Last Name

Today’s Date

Date of Birth

Gender

Please list your five major health concerns in order of importance

Please list any diagnoses or known medical issues that you have

Please list all medications (Over the counter or prescription), vitamins, and/or supplements that you take

What was the first day of your last period? If no period, please explain (hysterectomy, IUD, menopause, etc).

Part I

Please read the following questions and select the number that applies

Key:
0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly
2 = Consume or use weekly
3 = Consume or use daily

Diet

1. Alcohol

2. Artificial sweeteners

3. Candy, desserts, refined sugars

4. Carbonated beverages

5. Chewing tobacco

6. Cigarettes

7. Cigars/pipes

8. Caffeinated beverages

9. Fast foods

10. Fried foods

11. Luncheon meats

12. Margarine

13. Milk products

14. Radiation exposure (0 = no, 1 = yes)

15. Refined flour/baked goods

16. Vitamins and minerals

17. Water distilled

18. Water, tap

19. Water, well

20. Diet often for weight control

Lifestyle

21. 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)

22. Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)

23. Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)

24. Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)

Medications

Indicate any medications you’re currently taking or have taken in the last month (0 = no, 1 = yes)

25. Antacids

26. Antianxiety medications

27. Antibiotics

28. Anticonvulsants

29. Antidepressants

30. Antifungals

31. Aspirin/Ibuprofen

32. Asthma inhalers

33. Beta blockers

34. Birth control pills/implant contraceptives

35. Chemotherapy

36. Cholesterol lowering medications

37. Cortisone/steroids

38. Diabetic medications/insulin

39. Diuretics

40. Estrogen or progesterone (pharmaceutical, prescription)

41. Estrogen or progesterone (natural)

42. Heart medications

43. High blood pressure medications

44. Laxatives

45. Recreational drugs

46. Relaxants/Sleeping pills

47. Testosterone (natural or prescription)

48. Thyroid medication

49. Acetaminophen (Tylenol)

50. Ulcer medications

51. Sildenafal citrate (Viagra)

Part II

Please read the following questions and select the number that applies

Key:
0 = No, symptom does not occur
1 = yes, minor or mild symptom, rarely occurs (monthly)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)

Section 1 – Upper Gastrointestinal System

52. Belching or gas within one hour after eating

53. Heartburn or acid reflux

54. Bloating within one hour after eating

55. Vegan diet (no dairy, meat, fish or eggs) (0=no, 1=yes)

56. Bad breath (halitosis)

57. Loss of taste for meat

58. Sweat has a strong odor

59. Stomach upset by taking vitamins

60. Sense of excess fullness after meals

61. Feel like skipping breakfast

62. Feel better if you don’t eat

63. Sleepy after meals

64. Fingernails chip, peel or break easily

65. Anemia unresponsive to iron

66. Stomach pains or cramps

67. Diarrhea, chronic

68. Diarrhea shortly after meals

69. Black or tarry colored stools

70. Undigested food in stool

Section 2 – Liver and Gallbladder

Key:
0 = No, symptom does not occur
1 = 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

72. Stomach upset by greasy foods

73. Greasy or shiny stools

74. Nausea

75. Sea, car, airplane or motion sickness

76. History of morning sickness (0 = no, 1 = yes)

77. Light or clay colored stools

78. Dry skin, itchy feet or skin peels on feet

79. Headache over eyes

80. Gallbladder attacks (0=never, 1=years ago, 2=within last year, 3=within past 3 months)

81. Gallbladder removed (0=no, 1=yes)

82. Bitter taste in mouth, especially after meals

83. Become sick if you were to drink wine (0=no, 1=yes)

84. Easily intoxicated if you were to drink wine (0=no, 1=yes)

85. Easily hung over if you were to drink wine (0=no, 1=yes)

86. Alcohol per week (0=<3, 1=<7, 2 =14)

87. Recovering alcoholic (0=no, 1=yes)

88. History of drug or alcohol abuse (0=no, 1=yes)

89. History of hepatitis (0=no, 1=yes)

90. Long term use of prescription/recreational drugs (0=no, 1=yes)

91. Sensitive to chemicals (perfume, cleaning agents, etc.)

92. Sensitive to tobacco smoke

93. Exposure to diesel fumes

94. Pain under right side of rib cage

95. Hemorrhoids or varicose veins

96. Nutrasweet (aspartame) consumption

97. Sensitive to Nutrasweet (aspartame)

98. Chronic fatigue or Fibromyalgia

Section 3 – Small Intestine

Key:
0 = No, symptom does not occur
1 = yes, minor or mild symptom, rarely occurs (monthly)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)

99. Food allergies

100. Abdominal bloating 1 to 2 hours after eating

101. Specific foods make you tired or bloated (0=no, 1=yes)

102. Pulse speeds after eating

103. Airborne allergies

104. Experience hives

105. Sinus congestion, “stuffy head”

106. Crave bread or noodles

107. Alternating constipation and diarrhea

108. Crohn’s disease (0 =no, 1=yes in the past, 2=currently mild condition, 3=severe)

109. Wheat or grain sensitivity

110. Dairy sensitivity

111. Are there foods you could not give up (0=no, 1=yes)

112. Asthma, sinus infections, stuffy nose

113. Bizarre vivid dreams, nightmares

114. Use over-the-counter pain medications

115. Feel spacey or unreal

Section 4 – Large Intestine

Key:
0 = No, symptom does not occur
1 = yes, minor or mild symptom, rarely occurs (monthly)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)

116. Anus itches

117. Coated tongue

118. Feel worse in moldy or musty place

119. Taken antibiotic for a total accumulated time of (0=never, 1= <1 month, 2= 3 months)

120. Fungus or yeast infections

121. Ring worm, “jock itch”, “athletes foot”, nail fungus

122. Yeast symptoms increase with sugar, starch or alcohol

123. Stools hard or difficult to pass

124. History of parasites (0=no, 1=yes)

125. Less than one bowel movement per day

126. Stools have corners or edges, are flat or ribbon shaped

127. Stools are not well formed (loose)

128. Irritable bowel or mucus colitis

129. Blood in stool

130. Mucus in stool

131. Excessive foul smelling lower bowel gas

132. Bad breath or strong body odors

133. Painful to press along outer sides of thighs (Iliotibial Band)

134. Cramping in lower abdominal region

135. Dark circles under eyes

Section 5 – Mineral Needs

Key:
0 = No, symptom does not occur
1 = 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)

137. History of lower right abdominal pains or ileocecal valve problems (0=no, 1=yes)

138. History of stress fracture (0=no, 1=yes)

139. Bone loss (reduced density on bone scan)

140. Are you shorter than you used to be? (0=no, 1=yes)

141. Calf, foot or toe cramps at rest

142. Cold sores, fever blisters or herpes lesions

143. Frequent fevers

144. Frequent skin rashes and/or hives

145. Herniated disc (0=no, 1=yes)

146. Excessively flexible joints, “double jointed”

147. Joints pop or click

148. Pain or swelling in joints

149. Bursitis or tendonitis

150. History of bone spurs (0=no, 1=yes)

151. Morning stiffness

152. Nausea with vomiting

153. Crave chocolate

154. Feet have a strong odor

155. History of anemia

156. Whites of eyes (sclera) blue tinted

157. Hoarseness

158. Difficulty swallowing

159. Lump in throat

160. Dry mouth, eyes and/or nose

161. Gag easily

162. White spots on fingernails

163. Cuts heal slowly and/or scar easily

164. Decreased sense of taste or smell

Section 6 – Essential Fatty Acids

Key:
0 = No, symptom does not occur
1 = 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)

166. Crave fatty or greasy foods

167. Low- or reduced-fat diet (0=never, 1=years ago, 2=within past year, 3=currently)

168. Tension headaches at base of skull

169. Headaches when out in the hot sun

170. Sunburn easily or suffer sun poisoning

171. Muscles easily fatigued

172. Dry flaky skin or dandruff

Section 7 – Sugar Handling

Key:
0 = No, symptom does not occur
1 = 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

174. Crave sweets

175. Binge or uncontrolled eating

176. Excessive appetite

177. Crave coffee or sugar in the afternoon

178. Sleepy in afternoon

179. Fatigue that is relieved by eating

180. Headache if meals are skipped or delayed

181. Irritable before meals

182. Shaky if meals delayed

183. Family members with diabetes (0=none, 1=1 or 2, 2=3 or 4, 3=more than 4)

184. Frequent thirst

185. Frequent urination

Section 8 – Vitamin Need

Key:
0 = No, symptom does not occur
1 = 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

187. Feel exhausted or sore after moderate exercise

188. Vulnerable to insect bites

189. Loss of muscle tone, heaviness in arms/legs

190. Enlarged heart or congestive heart failure

191. Pulse below 65 per minute (0=no, 1=yes)

192. Ringing in the ears (Tinnitus)

193. Numbness, tingling or itching in hands and feet

194. Depressed

195. Fear of impending doom

196. Worrier, apprehensive, anxious

197. Nervous or agitated

198. Feelings of insecurity

199. Heart races

200. Can hear heart beat on pillow at night

201. Whole body or limb jerk as falling asleep

202. Night sweats

203. Restless leg syndrome

204. Cracks at corner of mouth (Cheilosis)

205. Fragile skin, easily chaffed, as in shaving

206. Polyps or warts

207. MSG sensitivity

208. Wake up without remembering dreams

209. Small bumps on back of arms

210. Strong light at night irritates eyes

211. Nose bleeds and/or tend to bruise easily

212. Bleeding gums especially when brushing teeth

Section 9 – Adrenal

Key:
0 = No, symptom does not occur
1 = 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”

214. Difficulty falling asleep

215. Slow starter in the morning

216. Tend to be keyed up, trouble calming down

217. Blood pressure above 120/80

218. Headache after exercising

219. Feeling wired or jittery after drinking coffee

220. Clench or grind teeth

221. Calm on the outside, troubled on the inside

222. Chronic low back pain, worse with fatigue

223. Become dizzy when standing up suddenly

224. Difficulty maintaining manipulative correction

225. Pain after manipulative correction

226. Arthritic tendencies

227. Crave salty foods

228. Salt foods before tasting

229. Perspire easily

230. Chronic fatigue, or get drowsy often

231. Afternoon yawning

232. Afternoon headache

233. Asthma, wheezing or difficulty breathing

234. Pain on the medial or inner side of the knee

235. Tendency to sprain ankles or “shin splints”

236. Tendency to need sunglasses

237. Allergies and/or hives

238. Weakness, dizziness

Section 10 – Pituitary

Key:
0 = No, symptom does not occur
1 = 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)

240. Early sexual development (before age 10) (0=no, 1=yes)

241. Increased libido

242. Splitting type headache

243. Memory failing

244. Tolerate sugar, feel fine when eating sugar (0=no, 1=yes)

245. Height under 4′ 10″ (0=no, 1=yes)

246. Decreased libido

247. Excessive thirst

248. Weight gain around hips or waist

249. Menstrual disorders

250. Delayed sexual development (after age 13) (0=no, 1=yes)

251. Tendency to ulcers or colitis

Section 11 – Thyroid

Key:
0 = No, symptom does not occur
1 = 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

253. Difficulty gaining weight, even with large appetite

254. Nervous, emotional, can’t work under pressure

255. Inward trembling

256. Flush easily

257. Fast pulse at rest

258. Intolerance to high temperatures

259. Difficulty losing weight

260. Mentally sluggish, reduced initiative

261. Easily fatigued, sleepy during the day

262. Sensitive to cold, poor circulation (cold hands and feet)

263. Constipation, chronic

264. Excessive hair loss and/or coarse hair

265. Morning headaches, wear off during the day

266. Loss of lateral 1/3 of eyebrow

267. Seasonal sadness

Section 12 – Men Only

Key:
0 = No, symptom does not occur
1 = yes, minor or mild symptom, rarely occurs (monthly)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)

268. Prostate problems

269. Difficulty with urination, dribbling

270. Difficult to start and stop urine stream

271. Pain or burning with urination

272. Waking to urinate at night

273. Interruption of stream during urination

274. Pain on inside of legs or heels

275. Feeling of incomplete bowel evacuation

276. Decreased sexual function

Section 13 – Women Only

Key:
0 = No, symptom does not occur
1 = yes, minor or mild symptom, rarely occurs (monthly)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, occurs frequently (daily)

277. Depression during periods

278. Mood swings associated with periods (PMS)

279. Crave chocolate around periods

280. Breast tenderness associated with cycle

281. Excessive menstrual flow

282. Scanty blood flow during periods

283. Occasional skipped periods

284. Variations in menstrual cycles

285. Endometriosis

286. Uterine fibroids

287. Breast fibroids, benign masses

288. Painful intercourse (dysparenia)

289. Vaginal discharge

290. Vaginal dryness

291. Vaginal itchiness

292. Gain weight around hips, thighs and buttocks

293. Excess facial or body hair

294. Hot flashes

295. Night sweats (in menopausal females)

296. Thinning skin

Section 14 – Cardiovascular

Key:
0 = No, symptom does not occur
1 = 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

298. Discomfort at high altitudes

299. “Air hunger” or sigh frequently

300. Compelled to open windows in a closed room

301. Shortness of breath with moderate exertion

302. Ankles swell, especially at end of day

303. Cough at night

304. Blush or face turns red for no reason

305. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion

306. Muscle cramps with exertion

Section 15 – Kidney and Bladder

Key:
0 = No, symptom does not occur
1 = 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

308. Puffy around the eyes, dark circles under eyes

309. History of kidney stones (0=no, 1=yes)

310. Cloudy, bloody or darkened urine

311. Urine has a strong odor

Section 16 – Immune system

Key:
0 = No, symptom does not occur
1 = 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

313. Catch colds at the beginning of winter

314. Mucus producing cough

315. 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)

316. 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)

317. 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)

318. Acne (adult)

319. Itchy skin (Dermatitis)

320. Cysts, boils, rashes

321. 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)

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