Nutritional Assessment Questionaire
Full Name:
First Name Last Name
Birth Date:
Day Month Year
Age:
Sex:
Male Female
Please list the 5 major health concerns in your order of importance:
Please check all that apply in each section:
Blood Sugar
I crave sweets and eat them, and though I get a temporary boost of energy, I later crash I have a family history of diabetes, hypoglycemia or alcoholism I get irritable, anxious, tired and jittery, or get headaches intermittently throughout the day, but feel better temporarily after meals I feel shaky 2-3 hours after a meal I eat a low-fat diet but can not seem to lose weight If i miss a meal, I feel cranky and irritable, weak, or tired If I eat a carbohydrate breakfast (muffin, bagel, cereal, pancakes etc..), I can't seem to control my eating for the rest of the day Once I start eating sweets or carbohydrates, I can't seem to stop If I eat fish or meat and vegetables, I feel good, but seem to get sleepy after eating a meal full of pasta, bread, potatoes, and dessert I go for the breadbasket at restaurants I seem salt sensitive (I tend to retain water) I am often moody, impatient, or anxious I get tired a few hours after eating My memory and concentration are poor I am tired most of the time I have extra weight around the middle I have high blood pressure I have type 2 diabetes I have a family history of diabetes
Fatty Acid
I have soft, cracked or brittle nails I have dry, itchy, scaling, or flaking skin I have dandruff I feel aching or stiffness in my joints I am thirsty most of the time I have fewer than two bowel movements a day I have light-colored, hard, or foul smelling stools I have poor mood, difficulty paying attention, and/or memory loss I have fibrocystic breasts I have premenstrual syndrome I have a family history of high LDL and/or low cholesterol, and high trigyycerides I am of North Atlantic genetic background (Irish, Scottish, Welsh, Scandinavian, or coastal Native American)
Inflammation
I have seasonal or environmental allergies I feel poorly after eating (sluggishness, headaches, congestion, confusion, phlegm) I work in an environment with poor lighting, chemicals, and poor ventilation I get frequent colds or infections I have a history of chronic infections (skin infections, canker sores, cold sores) I have allergies or get sinusitis I have asthma I have arthritis I have dermatitis (eczema, acne, rashes) I have an auto-immune condition (fibromyalgia, rheumatoid arthritis, lupus) I have colitis or inflammatory bowel disease I have irritable bowel syndrome (spastic colon) I exercise less than 30 minutes 3 times per week
Toxicity/Detoxification
I urinate small amounts of dark, strong smelling urine I rarely break into a real sweat I drink unfiltered tap water I get my clothes dry cleaned frequently I have more than one or two mercury amalgams ("silver fillings") I eat large fish (sword fish, tuna, shark) I regularly consume the following substances or medications (Tagamet, Zantac, Pepcid, Prilosec, Prevacid, ibuprofen, acetaminophen) I regularly consume foods containing (MSG, sulfites, sodium benzoate or other preservatives)
Social History
How many alcoholic beverages do you consume per week?
How many times do you eat out per day?
Per week?
How many caffeinated beverages do you consume per day?
How many times a week do you eat fish?
How many times a week do you eat raw nuts or seeds?
Do you smoke?
If yes, how many times per day?
How many times per week do you workout?
Please list all medications you are currently taking and for what conditions?
Please list all natural supplements you are currently taking and for what conditions?
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Nutritional Assessment Questionaire

Please check all that apply in each section:

Blood Sugar

Fatty Acid

Inflammation

Toxicity/Detoxification

Social History