Nutritional Assessment Questionnaire
This questionaire will take approx. 30 minutes to complete online. This questionaire will cost $19.95.
This is NOT A MEDICAL DIAGNOSIS
Always consult with your medical doctor prior to starting a nutritional program or discontinuing any prescription medications.

Name: Date:

Birthdate: Gender: Select One Male Femail

Please list your five major health concerns in order of importance:

1

2

3

4

5

PART I Read the following questions and fill in the number that applies:

KEY:

0 (or leave blank) = Do not consume or use 1 = Consume or use 2-3 times/month

2 = Consume or use weekly 3 = Consume or use daily

DIET

1. 0 1 2 3 Alcohol 2. 0 1 2 3 Artificial sweeteners 3. 0 1 2 3 Candy or other sweets 4. 0 1 2 3 Carbonated beverages 5. 0 1 2 3 Chewing tobacco 6. 0 1 2 3 Cigarettes 7. 0 1 2 3 Cigars/pipes

8. 0 1 2 3 Coffee 9. 0 1 2 3 Eat fast food regularly 10. 0 1 2 3 Fried foods 11. 0 1 2 3 Luncheon meats/ hot dogs 12. 0 1 2 3 Margarine 13. 0 1 2 3 Milk products 14. 0 1 2 3 Non-herbal tea

15. 0 1 2 3 Refined flour/ Baked goods 16. 0 1 2 3 Refined sugar 17. 0 1 2 3 Vitamins and minerals 18. 0 1 2 3 Water, distilled 19. 0 1 2 3 Water, Tap 20. 0 1 2 3 Water, well 21. 0 1 2 3 Diet often

LIFESTYLE

22. 0 1 2 3 Times you exercise per week (1 = once a week, 2 = 2-4 times/week, 3 = 5 times a week)

23. 0 1 2 3 Changed jobs (3= within last 2 months, 2= within last 6 months, 1= within last 12 months.)

24. 0 1 2 3 Divorced (3= within last 6 months, 2= within last year, 1= within last 2 years)

25. 0 1 2 3 Work over 60 hours/week (3= always, 2= usually, 1= occasionally, 0= never)

MEDICATIONS
Indicate with a checkmark or circle any medications you’re currently taking or have taken in the last month:

26. Antacids 27. Antibiotics 28. Anticonvulsants 29. Antidepressants 30. Antifungals 31. Aspirin/Ibuprofen

32. Asthma inhalers 33. Beta blockers 34. Chemotherapy 35. Cortisone 36. Diabetic medications 37. Diuretics

38. Estrogen/Progesterone 39. Heart medications 40. High blood pressure 41. Hormone Therapy 42. Laxatives 43. Insulin

44. Oral/implant contraceptives 45. Radiation exposure 46. Recreational drugs 47. Relaxants/Sleeping pills 48. Thyroid medication 49. Tylenol/acetaminophen 50. Ulcer medications

Other medications and dosages (if known):

PART II

Read the following questions and fill in the number that applies:
(How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:	0 (or leave blank) = No or Do not have the symptom, the symptom does not occur 1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less) 2 = It is a moderate symptom or it occasionally occurs (weekly) 3 = It is a severe symptom or it frequently occurs (daily)

Section 1 – Upper Gastrointestinal System

51. 0 1 2 3 Belching or gas within 1 hr. of a meal 52. 0 1 2 3 Heartburn or acid reflux 53. 0 1 2 3 Bloating shortly after eating 54. 0 1 2 3 Are you a vegan (no dairy, meat, fish or eggs) 55. 0 1 2 3 Bad breath (halitosis) 56. 0 1 2 3 Loss of taste for meat 57. 0 1 2 3 Sweat has a strong odor 58. 0 1 2 3 Stomach upset by taking vitamins 59. 0 1 2 3 Sense of excess fullness after meals

60. 0 1 2 3 Do you feel like skipping breakfast? 61. 0 1 2 3 Do you feel better if you don’t eat? 62. 0 1 2 3 Sleepy after meals 63. 0 1 2 3 Fingernails chip, peel or break easily 64. 0 1 2 3 Anemia unresponsive to iron 65. 0 1 2 3 Stomach pains or cramps 66. 0 1 2 3 Diarrhea, chronic 67. 0 1 2 3 Diarrhea shortly after meals 68. 0 1 2 3 Black or tarry stools 69. 0 1 2 3 Undigested food in stool

Section 2 – Liver and Gallbladder

70. 0 1 2 3 Pain between shoulder blades 71. 0 1 2 3 Stomach upset by greasy foods 72. 0 1 2 3 Greasy or shiny stools 73. 0 1 2 3 Nausea 74. 0 1 2 3 Sea, car or airplane sickness, motion sickness 75. 0 1 2 3 History of morning sickness (1 = yes, 0 = no) 76. 0 1 2 3 Light or clay colored stools 77. 0 1 2 3 Dry skin, itchy feet and/or skin peels on feet 78. 0 1 2 3 Headache over the eye 79. 0 1 2 3 Gallbladder attacks (past or present) 80. 0 1 2 3 Gallbladder removed (1 = yes, 0 = no) 81. 0 1 2 3 Bitter taste in mouth, especially after meals 82. 0 1 2 3 Become sick if drinking wine 83. 0 1 2 3 If drinking alcohol, easily intoxicated

84. 0 1 2 3 Alcoholic beverages per week (0 = < 3/ week, 1 = < 7/ week, 2 = < 14/ week, 3 = > 14/week) 85. 0 1 2 3 Recovering alcoholic (1 = yes, 0 = no) 86. 0 1 2 3 Hangovers after drinking alcohol 87. 0 1 2 3 History of drug or alcohol abuse (1 = yes, 0 = no) 88. 0 1 2 3 History of hepatitis (1 = yes, 0 = no) 89. 0 1 2 3 Long term use of prescription medications (1 = yes, 0 =no) 90. 0 1 2 3 Sensitive to chemicals (perfume, cleaning solvents, insecticides, exhaust, etc.) 91. 0 1 2 3 Sensitive to tobacco smoke 92. 0 1 2 3 Exposure to diesel fumes 93. 0 1 2 3 Pain under right side of rib cage 94. 0 1 2 3 Hemorrhoids or varicose veins 95. 0 1 2 3 Nutrasweet (aspartame) consumption 96. 0 1 2 3 Bothered by aspartame (Nutrasweet) 97. 0 1 2 3 Chronic fatigue or Fibromyalgia

Section 3 – Small Intestine

98. 0 1 2 3 Food allergies 99. 0 1 2 3 Abdominal bloating 1 to 2 hours after eating 100. 0 1 2 3 Specific foods make you tired or bloated (1= yes, 0= no) 101. 0 1 2 3 Pulse speeds after eating 102. 0 1 2 3 Airborne allergies 103. 0 1 2 3 Experience hives 104. 0 1 2 3 Sinus congestion, "stuffy head" 105. 0 1 2 3 Crave bread or noodles 106. 0 1 2 3 Alternating constipation and diarrhea

107. 0 1 2 3 Crohn's disease (1 = yes, 0 = no) 108. 0 1 2 3 Wheat or grain sensitivity 109. 0 1 2 3 Dairy sensitivity 110. 0 1 2 3 Are there foods you could not give up (1 = yes, 0 = no) 111. 0 1 2 3 Asthma, sinus infections, stuffy nose 112. 0 1 2 3 Bizarre vivid or nightmarish dreams 113. 0 1 2 3 Use over-the-counter pain medications 114. 0 1 2 3 Feel spacey or unreal

Section 4 – Large Intestine

115. _____ Anus itches 116. _____ Coated tongue 117. _____ Feel worse in moldy or musty place 118. _____ Taken any antibiotic for a combined time of (1 = < 1 mo., 2 = < 3 mos., 3 = > 3 mos.) 119. _____ Fungus or yeast infections 120. _____ Ring worm, "jock itch", "athletes foot", nail fungus 121. _____ Eating sugar, starch or drinking alcohol increases yeast symptoms 122. _____ Stools hard or difficult to pass 123. _____ History of parasites (1 = yes, 0 = no)

124. _____ Less than one bowel movement per day 125. _____ Stools have corners or edges are flat or ribbon shaped 126. _____ Stools are not well formed (loose) 127. _____ Irritable bowel or mucus colitis 128. _____ Blood in stool 129. _____ Mucus in stool 130. _____ Excessive foul smelling lower bowel gas 131. _____ Bad breath or strong body odors 132. _____ Painful to press along outer sides of thighs (Iliotibial Band) 133. _____ Cramping in lower abdominal region 134. _____ Dark circles under eyes

Section 5 – Mineral Needs

135. _____ History of Carpal Tunnel Syndrome (1 = yes, 0 = no) 136. _____ History of lower right abdominal pain (1 = yes, 0 = no) 137. _____ History of stress fractures 138. _____ Bone loss (reduced density on bone scan) 139. _____ Are you shorter than you used to be? (1 = yes, 0 = no) 140. _____ Calf, foot or toe cramps at rest 141. _____ Cold sores, fever blisters or herpes lesions 142. _____ Frequent fevers 143. _____ Frequent skin rashes and / or hives 144. _____ Have you ever had a herniated disc? (1 = yes, 0 = no) 145. _____ Excessively flexible joints, "double jointed" 146. _____ Joints pop or click 147. _____ Pain or swelling in joints 148. _____ Bursitis or tendonitis 149. _____ History of bone spurs (1 = yes, 0 = no)

150. _____ Morning stiffness 151. _____ Vomiting or nausea 152. _____ Crave chocolate 153. _____ Feet have a strong odor 154. _____ Tendency to anemia 155. _____ Whites of eyes (sclera) blue tinted