HTMA Re-Test

Overall, how likely are you to recommend working with Jensen Schoonover, FNTP to friends and family?
If you have any other feedback, please share it here. Continuous improvement is very important to me and I appreciate all constructive criticism. This will be kept confidential.
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Would you like to refer a friend or family member? Referrals are the greatest compliment and the heart of my business. They will receive a discount on any service they choose!
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Rows	Never	Monthly	Weekly	Daily
Drink Alcohol
Artificial Sweeteners
Candy, desserts, refined sugar
Carbonated beverages, including sparkling water
Chewing tobacco
Cigarettes
Cigars/Pipes
Caffeinated Beverages
Fast Foods
Fried Foods
Luncheon Meats
Margarine
Dairy products
Radiation exposure
Refined flour/Baked goods
Vitamins and Mineral Supplements
Distilled Water
Tap Water
Well Water
Diet for weight control

Rows	Never	Monthly	Weekly	Daily
Belching or gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (No=Never, Yes=Monthly)
Bad Breath
Loss of taste for meat
Sweat has a strong odor
Stomach gets upset from taking vitamins
Sense of excess fullness after meals
Feel like skipping breakfast
Feel better if you don't eat
Sleepy after meals
Fingernails chip, peel, or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or tarry colored stools
Undigested food in stool

Rows	Never or NO	Monthly or YES	Weekly	Daily
Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car, or airplane motion sickness
Light or clay colored stools
Dry skin, itchy feet, or skin peels on feet
Headache over eyes
Gallbladder attacks
History of morning sickness
Bitter taste in mouth, especially after meals
Alcoholic drinks per week (none, 1-3, 4-7, or 7+)
Exposure to diesel fumes
Pain under right side of rib cage
Nutrasweet or Aspartame consumption (typically in diet drinks, diet products)
Chronic fatigue or Fibromyalgia
Gallbladder removed
Become sick if you were to drink wine
Easily intoxicated if you were to drink wine
Easily hungover if you were to drink wine
Recovering Alcoholic
History or drug or alcohol abuse
History of hepatitis
Long term use of prescription or recreational drugs
Sensitive to chemicals (perfume, cleaning agents, etc)
Sensitive to tobacco smoke
Hemorrhoids or varicose veins

Rows	Never or NO	Monthly or YES	Weekly	Daily
Food allergies
Abdominal bloating 1-2 hours after eating
Specific foods make you tired or bloated
Pulse speeds after eating
Airborne allergies
Experience hives
Sinus congestion/stuffy head
Crave bread or noodles
Alternating constipation and diarrhea
Crohn's disease (No,Yes)
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up? (No,Yes)
Asthma, sinus infections, stuffy nose
Bizarre, vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

Rows	Never or NO	Monthly or YES	Weekly	Daily
Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotics for a total accumulated time of (Never taken antibiotics, Less than 1 month, 1-2 months, 3+ months)
Fungus or yeast infections
Ring worm, "jock itch", "athletes foot", nail fungus
Yeast symptoms increase with sugar, starch or alcohol. Examples of yeast symptoms include fatigue, poor memory,feeling 'spacey' or 'unreal', muscle aches or weakness, pain or swelling in joints, constipation, diarrhea or bloating.
Stools hard or difficult to pass
History of parasites
Less than one bowel movement per day
Stools have corners or edges, are flat, or ribbon shapped
Stools are not well formed (loose)
Irritable bowel or mucus colitis
Blood in stool
Mucus in stool
Excessive foul smelling lower bowel gas
Bad breath or strong body odors
Painful to press along the outer sides of the thighs
Cramping in lower abdominal region
Dark circles under eyes

Rows	Never or NO	Monthly or YES	Weekly	Daily
History of carpal tunnel syndrome
History of lower right abdominal pains or ileocecal valve problems
History of stress fracture
Bone loss (reduced density on bone scan)
Are you shorter than you used to be?
Calf, foot, or toe cramps at rest
Cold sores, fever blisters, or herpes lesions
Frequent fevers
Frequent skin rashes and/or hives
Herniated disc
Excessively flexible joints, "double jointed"
Joints pop or click
Pain or swelling in joints
Bursitis or tendonitis
History of bone spurs
Morning stiffness
Nausea with vomiting
Crave chocolate
Feet have a strong odor
History of anemia
Whites of eyes are blue tinted
Hoarseness in voice
Difficulty swallowing
Lump in throat
Dry mouth, eyes, and/or nose
Gag easily
White spots on fingernails
Cuts heal slowly and/or scar easily
Decreased sense of taste or smell

Rows	Never or NO	Monthly or YES	Weekly	Daily
Experience pain relief with aspirin
Crave fatty or greasy foods
Low or reduced-fat diet
Tension headaches at base of skull
Headaches when out in the hot sun
Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff

Rows	Never or NO	Monthly or YES	Weekly	Daily
Awaken a few hours after falling asleep, hard to get back to sleep
Crave sweets
Binge or uncontrolled eating
Excessive appetite
Crave coffee or sugar in the afternoon
Sleepy in the afternoon
Fatigue that is relieved by eating
Headache if meals are skipped or delayed
Irritable before meals
Shaky if meals delayed
Family members with diabetes
Frequent thirst
Frequent urination

Rows	Never or NO	Monthly or YES	Weekly	Daily
Muscles easily become fatigued
Feel exhausted or sore after moderate exercise
Vulnerable to insect bites
Loss of muscle tone, heaviness in arms/legs
Enlarged heart or congestive heart failure
Pulse below 65 per minute
Ringing in the ears
Numbness, tingling, or itching in hands and feet
Depressed
Fear of impending doom
Worrier, apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart races
Can hear heart beat on pillow at night
Whole body or limb jerk as falling asleep
Night sweats
Restless leg syndrome
Cracks at corner of mouth
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and/or tend to bruise easily
Bleeding gums especially when brushing teeth

Nutritional Assessment Questionnaire - Re-test