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Intake
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Family History
Nutritional Assessment Questionnaire
PART 1
AFTER EACH SECTION, PLEASE ADD UP YOUR INDIVIDUAL SCORES AND ENTER INTO APPROPRIATE BOX FOR TOTAL SECTION POINTS. This applies for both Part 1 and 2
Diet (58)
Read the following questions and pick the number that applies in the box: 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
1. Alcohol
2. Artificial sweeteners
3. Candy, desserts, refined sugar
0 1 2 3
4. Carbonated beverages
5. Chewing tobacco
6. Cigarettes
7. Cigars/pipes
8. Caffeinated beverages
9. Fast foods
9. Radiation Exposure
1 = No 2 = Yes
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
Total Points for Diet
Lifestyle (12)
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)
Total Points for Lifestyle
Medications (54)
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 / hormone implants
35. Chemotherapy
36. Cholesterol lowering
37. Cortisone / Steroids
38. Diabetic medications / insulin
39. Diuretics
40. Estrogen or Progesterone (pharmaceutical prescription)
41. Estrogen or Progesterone (natural or bioidentical)
42. Heart medications
43. High blood pressure medications
44. Laxatives
45. Recreational drugs
46. Relaxants / sleeping pills
47. Testosterone (natural or prescribed)
48. Thyroid medication
49. Acetaminophen (Tylenol)
50. Ulcer medications
51. Sildenafal citrate (Viagra)
Total Points Medications
Part II
Section 1 - Upper Gastrointestinal System (55)
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)
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
Total Points for Section 1
Section 2 – Liver and Gallbladder (68)
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, 3=>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
Total Points Section 2
Section 3 – Small Intestine (47)
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
Total Points Section 3
Section 4 – Large Intestine (58)
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, 3= >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
Total Points Section 4
Section 5 – Mineral Needs (75)
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
Total Points Section 5
Section 6 – Essential Fatty Acids (22)
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
Total Points for Section 6
Section 7 – Sugar Handling (39)
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
Total Points Section 7
Section 8 – Vitamin Need (81)
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
Total Points Section 8
Section 9 – Adrenal (78)
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
Total Points Section 9
Section 10 – Pituitary (29)
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
Total Points for Section 10
Section 11 – Thyroid (48)
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
Total Points for Section 11
Section 12 – Men Only (27)
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
Total Points for Section 12
Section 13 – Women Only (60)
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
Total Points Section 13
Section 14 – Cardiovascular (30)
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
Total Points for Section 14
Section 15 – Kidney and Bladder (13)
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
Total Points Section 15
Section 16 – Immune system (30)
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)
Total Points Section 16

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