Nutritional Assessment Questionnaire

 

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

  • 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

  • Lifestyle

    (0 = 2 or more times a week, 1 = 1 times a week, 2 = 1 or 2 times a month, 3 = never, less than once a month)
    (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
    (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
    (0 = never, 1 = occasionally, 2 = usually, 3 = always)
  • Medications

  • Indicate any medications you're currently taking or have taken in the last month:
  • PART II

  • 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

    ( 0 = no, 1 = yes)
  • Section 2 – Liver and Gallbladder

    ( 0 = no, 1 = yes)
    ( 0 = never, 1 = years ago, 2 = within last year, 3 = within past 3 months)
    (0 = no, 1 = yes)
    ( 0 = no, 1 = yes)
    (0 = no, 1 = yes)
    (0 = no, 1 = yes)
    ( 0 = < 3, 1 = < 7, 2 = < 14, 3 = > 14)
    (0 = no, 1 = yes)
    (0 = no, 1 = yes)
    (0 = no, 1 = yes)
    (0 = no, 1 = yes)
  • Section 3 – Small Intestine

    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe)
    ( 0 = no, 1 = yes )
  • Section 4 – Large Intestine

    ( 0 = never, 1 = < 1 month, 2 = < 3 months, 3 = > 3 months )
    ( 0 = no, 1 = yes )
  • Section 5 – Mineral Needs

    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes)
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
  • Section 6 – Essential Fatty Acids

    ( 0 = no, 1 = yes)
    ( 0 = never, 1 = years ago, 2 = within past year 3 = currently )
  • Section 7 - Sugar Handling

    ( 0 = none, 1 = 1 or 2, 2 = 3 or 4, 3 = more than 4 )
  • Section 8 – Vitamin Need

    ( 0 = no, 1 = yes )
  • Section 9 – Adrenal

  • Section 10 – Pituitary

    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
    ( 0 = no, 1 = yes )
  • Section 11 – Thyroid

  • Section 12 – Men Only

  • Section 13 - Women Only

  • Section 14 – Cardiovascular

  • Section 15 – Kidney and Bladder

  • Section 16

    ( 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 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 = sickly 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 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe )


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