Ohio Pain & Rehabiliation | Nutritional Assessment Questionnaire

Nutritional Assessment Questionnaire

Name*
E-mail*
Birth Date*
Gender*
Please list your five major health concerns in order of importance:
1.*
2.*
3.*
4.*
5.*
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
1. Alcohol
- 0
- 1
- 2
- 3
2. Artificial Sweeteners
- 0
- 1
- 2
- 3
3. Candy, Desserts, Refined Sugar
- 0
- 1
- 2
- 3
4. Carbonated Beverages
- 0
- 1
- 2
- 3
5. Chewing Tobacco
- 0
- 1
- 2
- 3
6. Cigarettes
- 0
- 1
- 2
- 3
7. Cigars/Pipes
- 0
- 1
- 2
- 3
8. Caffeinated Beverages
- 0
- 1
- 2
- 3
9. Fast Foods
- 0
- 1
- 2
- 3
10. Fried Foods
- 0
- 1
- 2
- 3
11. Luncheon Meats
- 0
- 1
- 2
- 3
12. Margarine
- 0
- 1
- 2
- 3
13. Milk Products
- 0
- 1
- 2
- 3
14. Radiation Exposure
- 0
- 1
- 2
- 3
15. Refined Flour/Baked Goods
- 0
- 1
- 2
- 3
16. Vitamins and Minerals
- 0
- 1
- 2
- 3
17. Water, Distilled
- 0
- 1
- 2
- 3
18. Water, Tap
- 0
- 1
- 2
- 3
19. Water, Well
- 0
- 1
- 2
- 3
20. Diet Often for Weight Control
- 0
- 1
- 2
- 3
Lifestyle
21. Exercise per week
- 0
- 1
- 2
- 3
(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)
22. Changed jobs
- 0
- 1
- 2
- 3
(0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
23. Divorced
- 0
- 1
- 2
- 3
(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
- 1
- 2
- 3
(0 = never, 1 = occasionally, 2 = usually, 3 = always)
Medications
Indicate any medications you're currently taking or have taken in the last month:
25. Antacids
- Yes
- No
26. Antianxiety Medications
- Yes
- No
27. Antibiotics
- Yes
- No
28. Anticonvulsants
- Yes
- No
29. Antidepressants
- Yes
- No
30. Antifungals
- Yes
- No
31. Aspirin/Ibuprofen
- Yes
- No
32. Asthma Inhalers
- Yes
- No
33. Beta Blockers
- Yes
- No
34. Birth Control Pills/Implant Contraceptives
- Yes
- No
35. Chemotherapy
- Yes
- No
36. Cholesterol Lowering Medications
- Yes
- No
37. Cortisone/Steroids
- Yes
- No
38. Diabetic Medications/Insulin
- Yes
- No
39. Diuretics
- Yes
- No
40. Estrogen or Progesterone (Pharmaceutical, Prescription)
- Yes
- No
41. Estrogen or Progesterone (Natural)
- Yes
- No
42. Heart Medications
- Yes
- No
43. High Blood Pressure Medications
- Yes
- No
44. Laxatives
- Yes
- No
45. Recreational Drugs
- Yes
- No
46. Relaxants/Sleeping Pills
- Yes
- No
47. Testosterone (Natural or Prescription)
- Yes
- No
49. Acetaminophen (Tylenol)
- Yes
- No
50. Ulcer Medications
- Yes
- No
51. Sildenafil Citrate (Viagra)
- Yes
- No
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
52. Belching or gas within one hour after eating
- 0
- 1
- 2
- 3
53. Heartburn or acid reflux
- 0
- 1
- 2
- 3
54. Bloating within one hour after eating
- 0
- 1
- 2
- 3
55. Vegan diet (no dairy, meat, fish, or egg)
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes)
56. Bad breath (halitosis)
- 0
- 1
- 2
- 3
57. Loss of taste for meat
- 0
- 1
- 2
- 3
58. Sweat has a strong odor
- 0
- 1
- 2
- 3
59. Stomach upset by taking vitamins
- 0
- 1
- 2
- 3
60. Sense of excess fullness after meals
- 0
- 1
- 2
- 3
61. Feel like skipping breakfast
- 0
- 1
- 2
- 3
62. Feel better if you don’t eat
- 0
- 1
- 2
- 3
63. Sleepy after meals
- 0
- 1
- 2
- 3
64. Fingernails chips, peel, or break easily
- 0
- 1
- 2
- 3
65. Anemia unresponsive to iron
- 0
- 1
- 2
- 3
66. Stomach pains or cramps
- 0
- 1
- 2
- 3
67. Diarrhea, chronic
- 0
- 1
- 2
- 3
68. Diarrhea shortly after meals
- 0
- 1
- 2
- 3
69. Black or tarry colored stools
- 0
- 1
- 2
- 3
70. Undigested food in stool
- 0
- 1
- 2
- 3
Section 2 – Liver and Gallbladder
71. Pain between shoulder blades
- 0
- 1
- 2
- 3
72. Stomach upset by greasy foods
- 0
- 1
- 2
- 3
73. Greasy or shiny stools
- 0
- 1
- 2
- 3
74. Nausea
- 0
- 1
- 2
- 3
75. Sea, car, airplane, or motion sickness
- 0
- 1
- 2
- 3
76. History of morning sickness
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes)
77. Light or clay colored stools
- 0
- 1
- 2
- 3
78. Dry skin, itchy feet, or skin peels on feet
- 0
- 1
- 2
- 3
79. Headache over eyes
- 0
- 1
- 2
- 3
80. Gallbladder attacks
- 0
- 1
- 2
- 3
( 0 = never, 1 = years ago, 2 = within last year, 3 = within past 3 months)
81. Gallbladder removed
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
82. Bitter taste in mouth, especially after meals
- 0
- 1
- 2
- 3
83. Become sick if you were to drink wine
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes)
84. Easily intoxicated if you were to drink wine
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
85. Easily hung over if you were to drink wine
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
86. Alcohol per week
- 0
- 1
- 2
- 3
( 0 = < 3, 1 = < 7, 2 = < 14, 3 = > 14)
87. Recovering alcoholic
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
88. History of drug or alcohol abuse
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
89. History of hepatitis
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
90. Long term use of prescription/recreational drugs
- 0
- 1
- 2
- 3
(0 = no, 1 = yes)
91. Sensitive to chemicals (perfume, cleaning agents, etc.)
- 0
- 1
- 2
- 3
92. Sensitive to tobacco smoke
- 0
- 1
- 2
- 3
93. Exposure to diesel fumes
- 0
- 1
- 2
- 3
94. Pain under right side of rib cage
- 0
- 1
- 2
- 3
95. Hemorrhoids or varicose veins
- 0
- 1
- 2
- 3
96. Nutrasweet (aspartame) consumption
- 0
- 1
- 2
- 3
97. Sensitive to Nutrasweet (aspartame)
- 0
- 1
- 2
- 3
98. Chronic fatigue or Fibromyalgia
- 0
- 1
- 2
- 3
Section 3 – Small Intestine
99. Food allergies
- 0
- 1
- 2
- 3
100. Abdominal bloating 1 to 2 hours after eating
- 0
- 1
- 2
- 3
101. Specific foods make you tired or bloated
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
102. Pulse speeds after eating
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
103. Airborne allergies
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
104. Experience hives
- 0
- 1
- 2
- 3
105. Sinus congestion, “stuffy head”
- 0
- 1
- 2
- 3
106. Crave bread or noodles
- 0
- 1
- 2
- 3
107. Alternating constipation and diarrhea
- 0
- 1
- 2
- 3
108. Crohn’s disease
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe)
109. Wheat or grain sensitivity
- 0
- 1
- 2
- 3
110. Dairy sensitivity
- 0
- 1
- 2
- 3
111. Are there foods you could not give up
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
112. Asthma, sinus infections, stuffy nose
- 0
- 1
- 2
- 3
113. Bizarre vivid dreams, nightmares
- 0
- 1
- 2
- 3
114. Use over-the-counter pain medications
- 0
- 1
- 2
- 3
115. Feel spacey or unreal
- 0
- 1
- 2
- 3
Section 4 – Large Intestine
116. Anus itches
- 0
- 1
- 2
- 3
117. Coated tongue
- 0
- 1
- 2
- 3
118. Feel worse in moldy or musty place
- 0
- 1
- 2
- 3
119. Taken antibiotic for a total accumulated time of
- 0
- 1
- 2
- 3
( 0 = never, 1 = < 1 month, 2 = < 3 months, 3 = > 3 months )
120. Fungus or yeast infections
- 0
- 1
- 2
- 3
121. Ring worm, “jock itch”, athlete’s foot”, nail fungus
- 0
- 1
- 2
- 3
122. Yeast symptoms increase with sugar, starch, or alcohol
- 0
- 1
- 2
- 3
123. Stools hard or difficult to pass
- 0
- 1
- 2
- 3
124. History of parasites
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
125. Less than one bowel movement per day
- 0
- 1
- 2
- 3
126. Stools have corners or edges, are flat or ribbon shaped
- 0
- 1
- 2
- 3
127. Stools are not well formed
- 0
- 1
- 2
- 3
128. Irritable bowel or mucus colitis
- 0
- 1
- 2
- 3
129. Blood in stool
- 0
- 1
- 2
- 3
130. Mucus in stool
- 0
- 1
- 2
- 3
131. Excessive foul smelling lower bowel gas
- 0
- 1
- 2
- 3
132. Bad breath or strong body odors
- 0
- 1
- 2
- 3
133. Painful to press along outer sides of thighs (Iliotibial Band)
- 0
- 1
- 2
- 3
134. Cramping in lower abdominal region
- 0
- 1
- 2
- 3
135. Dark circles under eyes
- 0
- 1
- 2
- 3
Section 5 – Mineral Needs
136. History of carpal tunnel syndrome
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
137. History of lower right abdominal pains or ileocecal valve problems
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes)
138. History of stress fracture
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
139. Bone loss (reduced density on bone scan)
- 0
- 1
- 2
- 3
140. Are you shorter than you used to be?
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
141. Calf, foot, or toe cramps at rest
- 0
- 1
- 2
- 3
142. Cold sores, fever blisters, or herpes lesions
- 0
- 1
- 2
- 3
143. Frequent fevers
- 0
- 1
- 2
- 3
144. Frequent skin rashes and/or hives
- 0
- 1
- 2
- 3
145. Herniated disc
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
146. Excessively flexible joints, “double jointed”
- 0
- 1
- 2
- 3
147. Joints pop or click
- 0
- 1
- 2
- 3
148. Pain or swelling in joints
- 0
- 1
- 2
- 3
149. Bursitis or tendonitis
- 0
- 1
- 2
- 3
150. History of bone spurs
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
151. Morning stiffness
- 0
- 1
- 2
- 3
152. Nausea with vomiting
- 0
- 1
- 2
- 3
153. Crave chocolate
- 0
- 1
- 2
- 3
154. Feet have a strong odor
- 0
- 1
- 2
- 3
155. History of anemia
- 0
- 1
- 2
- 3
156. Whites of eyes (sclera) blue tinted
- 0
- 1
- 2
- 3
157. Hoarseness
- 0
- 1
- 2
- 3
158. Difficulty swallowing
- 0
- 1
- 2
- 3
159. Lump in throat
- 0
- 1
- 2
- 3
160. Dry mouth, eyes, and/or nose
- 0
- 1
- 2
- 3
161. Gag easily
- 0
- 1
- 2
- 3
162. White spots on fingernails
- 0
- 1
- 2
- 3
163. Cuts heal slowly and/or scar easily
- 0
- 1
- 2
- 3
164. Decreased sense of taste or smell
- 0
- 1
- 2
- 3
Section 6 – Essential Fatty Acids
165. Experience pain relief with aspirin
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes)
166. Crave fatty or greasy foods
- 0
- 1
- 2
- 3
167. Low or reduced fat diet
- 0
- 1
- 2
- 3
( 0 = never, 1 = years ago, 2 = within past year 3 = currently )
168. Tension headaches at base of skull
- 0
- 1
- 2
- 3
169. Headaches when out in the hot sun
- 0
- 1
- 2
- 3
170. Sunburn easily or suffer sun poisoning
- 0
- 1
- 2
- 3
171. Muscles easily fatigued
- 0
- 1
- 2
- 3
172. Dry flaky skin or dandruff
- 0
- 1
- 2
- 3
Section 7 - Sugar Handling
173. Awaken a few hours after falling asleep, hard to get back to sleep
- 0
- 1
- 2
- 3
174. Crave sweets
- 0
- 1
- 2
- 3
175. Binge or uncontrolled eating
- 0
- 1
- 2
- 3
176. Excessive appetite
- 0
- 1
- 2
- 3
177. Crave coffee or sugar in the afternoon
- 0
- 1
- 2
- 3
178. Sleepy in afternoon
- 0
- 1
- 2
- 3
179. Fatigue that is relieved by eating
- 0
- 1
- 2
- 3
180. Headache is meals are skipped or delayed
- 0
- 1
- 2
- 3
181. Irritable before meals
- 0
- 1
- 2
- 3
182. Shaky if meals delayed
- 0
- 1
- 2
- 3
183. Family members with diabetes
- 0
- 1
- 2
- 3
( 0 = none, 1 = 1 or 2, 2 = 3 or 4, 3 = more than 4 )
184. Frequent thirst
- 0
- 1
- 2
- 3
185. Frequent urination
- 0
- 1
- 2
- 3
Section 8 – Vitamin Need
186. Muscles become easily fatigued
- 0
- 1
- 2
- 3
187. Feel exhausted or sore after moderate exercise
- 0
- 1
- 2
- 3
188. Vulnerable to insect bites
- 0
- 1
- 2
- 3
189. Loss of muscle tone, heaviness in arms/legs
- 0
- 1
- 2
- 3
190. Enlarged heart or congestive heart failure
- 0
- 1
- 2
- 3
191. Pulse below 65 per minute
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
192. Ringing in the ears (Tinnitus)
- 0
- 1
- 2
- 3
193. Numbness, tingling, or itching in hands and feet
- 0
- 1
- 2
- 3
194. Depressed
- 0
- 1
- 2
- 3
195. Fear of impending doom
- 0
- 1
- 2
- 3
196. Worrier, apprehensive, anxious
- 0
- 1
- 2
- 3
197. Nervous or agitated
- 0
- 1
- 2
- 3
198. Feelings of insecurity
- 0
- 1
- 2
- 3
199. Heart races
- 0
- 1
- 2
- 3
200. Can hear heartbeat on pillow at night
- 0
- 1
- 2
- 3
201. Whole body or limb jerk as falling asleep
- 0
- 1
- 2
- 3
202. Night sweats
- 0
- 1
- 2
- 3
203. Restless leg syndrome
- 0
- 1
- 2
- 3
204. Cracks at corner of mouth (Cheilosis)
- 0
- 1
- 2
- 3
205. Fragile skin, easily chaffed, as in shaving
- 0
- 1
- 2
- 3
206. Polyps or warts
- 0
- 1
- 2
- 3
207. MSG sensitivity
- 0
- 1
- 2
- 3
208. Wake up without remembering dreams
- 0
- 1
- 2
- 3
209. Small bumps on back of arms
- 0
- 1
- 2
- 3
210. Strong light at night irritates eyes
- 0
- 1
- 2
- 3
211. Nose bleeds and/or tend to bruise easily
- 0
- 1
- 2
- 3
212. Bleeding gums especially when brushing teeth
- 0
- 1
- 2
- 3
Section 9 – Adrenal
213. Tend to be a “night person”
- 0
- 1
- 2
- 3
214. Difficulty falling asleep
- 0
- 1
- 2
- 3
215. Slow starter in the morning
- 0
- 1
- 2
- 3
216. Tend to be keyed up, trouble calming down
- 0
- 1
- 2
- 3
217. Blood pressure above 120/80
- 0
- 1
- 2
- 3
218. Headache after exercising
- 0
- 1
- 2
- 3
219. Feeling wired or jittery after drinking coffee
- 0
- 1
- 2
- 3
220. Clench or grind teeth
- 0
- 1
- 2
- 3
221. Calm on the outside, troubled on the inside
- 0
- 1
- 2
- 3
222. Chronic low back pain, worse with fatigue
- 0
- 1
- 2
- 3
223. Become dizzy when standing up suddenly
- 0
- 1
- 2
- 3
224. Difficulty maintaining manipulative correction
- 0
- 1
- 2
- 3
225. Pain after manipulative correction
- 0
- 1
- 2
- 3
226. Arthritic tendencies
- 0
- 1
- 2
- 3
227. Crave salty foods
- 0
- 1
- 2
- 3
228. Salt foods before tasting
- 0
- 1
- 2
- 3
229. Perspire easily
- 0
- 1
- 2
- 3
230. Chronic fatigue, or get drowsy often
- 0
- 1
- 2
- 3
231. Afternoon yawning
- 0
- 1
- 2
- 3
232. Afternoon headache
- 0
- 1
- 2
- 3
233. Asthma, wheezing, or difficulty breathing
- 0
- 1
- 2
- 3
234. Pain on the medial or inner side of the knee
- 0
- 1
- 2
- 3
235. Tendency to sprain ankles or “shin splints”
- 0
- 1
- 2
- 3
236. Tendency to need sunglasses
- 0
- 1
- 2
- 3
237. Allergies/and or hives
- 0
- 1
- 2
- 3
238. Weakness, dizziness
- 0
- 1
- 2
- 3
Section 10 – Pituitary
239. Height over 6’ 6”
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
240. Early sexual development (before age 10)
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
241. Increased libido
- 0
- 1
- 2
- 3
242. Splitting type headache
- 0
- 1
- 2
- 3
243. Memory failing
- 0
- 1
- 2
- 3
244. Tolerate sugar, feel fine when eating sugar
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
245. Height under 4’ 10 “
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
246. Decreased libido
- 0
- 1
- 2
- 3
247. Excessive thirst
- 0
- 1
- 2
- 3
248. Weight gain around hips or waist
- 0
- 1
- 2
- 3
249. Menstrual disorders
- 0
- 1
- 2
- 3
250. Delayed sexual development (after age 13)
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes )
251. Tendency to ulcers or colitis
- 0
- 1
- 2
- 3
Section 11 – Thyroid
252. Sensitive/allergic to iodine
- 0
- 1
- 2
- 3
253. Difficulty gaining weight, even with large appetite
- 0
- 1
- 2
- 3
254. Nervous, emotional, can’t work under pressure
- 0
- 1
- 2
- 3
255. Inward trembly
- 0
- 1
- 2
- 3
256. Flush easily
- 0
- 1
- 2
- 3
257. Fast pulse at rest
- 0
- 1
- 2
- 3
258. Intolerance to high temperatures
- 0
- 1
- 2
- 3
259. Difficulty losing weight
- 0
- 1
- 2
- 3
260. Mentally sluggish, reduced initiative
- 0
- 1
- 2
- 3
261. Easily fatigued, sleep during the day
- 0
- 1
- 2
- 3
262. Sensitive to cold, poor circulation ( cold hands and feet )
- 0
- 1
- 2
- 3
263. Constipation, chronic
- 0
- 1
- 2
- 3
264. Excessive hair loss and/or coarse hair
- 0
- 1
- 2
- 3
265. Morning headaches. Wear off during the day
- 0
- 1
- 2
- 3
266. Loss of lateral 1/3 of eyebrow
- 0
- 1
- 2
- 3
267. Seasonal sadness
- 0
- 1
- 2
- 3
Section 12 – Men Only
268. Prostate problems
- 0
- 1
- 2
- 3
269. Difficulty with urination, dribbling
- 0
- 1
- 2
- 3
270. Difficult to start and stop urine stream
- 0
- 1
- 2
- 3
271. Pain or burning with urination
- 0
- 1
- 2
- 3
272. Waking to urinate at night
- 0
- 1
- 2
- 3
273. Interruption of stream during urination
- 0
- 1
- 2
- 3
274. Pain on inside of legs or heels
- 0
- 1
- 2
- 3
275. Feeling of incomplete bowel evacuation
- 0
- 1
- 2
- 3
276. Decreased sexual function
- 0
- 1
- 2
- 3
Section 13 - Women Only
277. Depression during periods
- 0
- 1
- 2
- 3
277. Depression during periods
- 0
- 1
- 2
- 3
278. Mood swings associated with periods (PMS)
- 0
- 1
- 2
- 3
279. Crave chocolate around periods
- 0
- 1
- 2
- 3
280. Breast tenderness associated with cycle
- 0
- 1
- 2
- 3
281. Excessive menstrual flow
- 0
- 1
- 2
- 3
282. Scanty blood flow during periods
- 0
- 1
- 2
- 3
283. Occasional skipped periods
- 0
- 1
- 2
- 3
284. Variations in menstrual cycles
- 0
- 1
- 2
- 3
285. Endometriosis
- 0
- 1
- 2
- 3
286. Uterine Fibroids
- 0
- 1
- 2
- 3
287. Breast fibroids, benign masses
- 0
- 1
- 2
- 3
288. Painful intercourse (dyspareunia)
- 0
- 1
- 2
- 3
289. Vaginal discharge
- 0
- 1
- 2
- 3
290. Vaginal dryness
- 0
- 1
- 2
- 3
291. Vaginal itchiness
- 0
- 1
- 2
- 3
292. Gain weight around hips, thighs, and buttocks
- 0
- 1
- 2
- 3
293. Excess facial or body hair
- 0
- 1
- 2
- 3
294. Hot flashes
- 0
- 1
- 2
- 3
295. Night sweats (in menopausal females)
- 0
- 1
- 2
- 3
296. Thinning skin
- 0
- 1
- 2
- 3
Section 14 – Cardiovascular
297. Aware of heavy and/or irregular breathing
- 0
- 1
- 2
- 3
298. Discomfort at high altitudes
- 0
- 1
- 2
- 3
299. “Air hunger” or sigh frequently
- 0
- 1
- 2
- 3
300. Compelled to open windows in a closed room
- 0
- 1
- 2
- 3
301. Shortness of breath with moderate exertion
- 0
- 1
- 2
- 3
302. Ankles swell, especially at end of day
- 0
- 1
- 2
- 3
303. Cough at night
- 0
- 1
- 2
- 3
304. Blush or face turns red for no reason
- 0
- 1
- 2
- 3
305. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
- 0
- 1
- 2
- 3
306. Muscle cramps with exertion
- 0
- 1
- 2
- 3
Section 15 – Kidney and Bladder
307. Pain in mid-back region
- 0
- 1
- 2
- 3
308. Puffy around the eyes, dark circles under eyes
- 0
- 1
- 2
- 3
309. History of kidney stones ( 0 = no, 1 = yes )
- 0
- 1
- 2
- 3
310. Cloudy, bloody, or darkened urine
- 0
- 1
- 2
- 3
311. Urine has a strong odor
- 0
- 1
- 2
- 3
Section 16
312. Runny or drippy nose
- 0
- 1
- 2
- 3
313. Catch colds at the beginning of winter
- 0
- 1
- 2
- 3
314. Mucus producing cough
- 0
- 1
- 2
- 3
315. Frequent colds or flu
- 0
- 1
- 2
- 3
( 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
- 2
- 3
( 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
- 1
- 2
- 3
( 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 )
318. Acne (adult)
- 0
- 1
- 2
- 3
319. Itchy skin (Dermatitis)
- 0
- 1
- 2
- 3
320. Cysts, boils, rashes
- 0
- 1
- 2
- 3
321. History of Epstein bar, Mono, Herpes or other chronic viral condition
- 0
- 1
- 2
- 3
( 0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe )

Nutritional Assessment Questionnaire

PART I

Diet

Lifestyle

Medications

PART II

Section 1 - Upper Gastrointestinal System

Section 2 – Liver and Gallbladder

Section 3 – Small Intestine

Section 4 – Large Intestine

Section 5 – Mineral Needs

Section 6 – Essential Fatty Acids

Section 7 - Sugar Handling

Section 8 – Vitamin Need

Section 9 – Adrenal

Section 10 – Pituitary

Section 11 – Thyroid

Section 12 – Men Only

Section 13 - Women Only

Section 14 – Cardiovascular

Section 15 – Kidney and Bladder

Section 16

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