Mineral Deficiency Assessment Form
Please complete the Mineral Deficiency Assessment Form to help identify possible concerns related to mineral deficiencies. All responses are confidential and used solely for assessment purposes.
Age
*
Gender
*
Male
Female
Prefer not to say
Other
How would you rate your overall diet in terms of mineral-rich foods (e.g., leafy greens, nuts, seeds, whole grains, dairy)?
*
1
2
3
4
5
Do you follow any special diet?
*
Vegetarian
Vegan
Gluten-free
No special diet
Other
In the past month, have you experienced any of the following symptoms? (Select all that apply)
*
Fatigue or low energy
Muscle cramps or weakness
Brittle nails or hair
Numbness or tingling
Frequent headaches
No symptoms
Other
How severe are your symptoms overall?
*
Not severe
1
2
3
4
Very severe
5
1 is Not severe, 5 is Very severe
Please indicate your intake frequency for the following mineral sources:
*
Rows
Never
Rarely
Sometimes
Often
Daily
Leafy green vegetables
1
2
3
4
5
Nuts and seeds
6
7
8
9
10
Dairy products
11
12
13
14
15
Whole grains
16
17
18
19
20
Fortified foods
21
22
23
24
25
Do you have any of the following risk factors? (Select all that apply)
*
Chronic illness (e.g., diabetes, kidney disease)
Recent surgery or injury
Regular use of medications affecting mineral absorption
Pregnancy or breastfeeding
No known risk factors
Other
Have you previously been diagnosed with a mineral deficiency?
*
Yes
No
Not sure
How concerned are you about having a mineral deficiency?
*
1
2
3
4
5
Submit Assessment
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