Nutritional Assessment Questionnaire Form

Nutritional Assessment Questionaire
Full Name:
First NameLast Name
Birth Date:
DayMonthYear
Age:
Sex:
MaleFemale
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 crashI have a family history of diabetes, hypoglycemia or alcoholismI get irritable, anxious, tired and jittery, or get headaches intermittently throughout the day, but feel better temporarily after mealsI feel shaky 2-3 hours after a mealI eat a low-fat diet but can not seem to lose weightIf i miss a meal, I feel cranky and irritable, weak, or tiredIf I eat a carbohydrate breakfast (muffin, bagel, cereal, pancakes etc..), I can't seem to control my eating for the rest of the dayOnce I start eating sweets or carbohydrates, I can't seem to stopIf 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 dessertI go for the breadbasket at restaurantsI seem salt sensitive (I tend to retain water)I am often moody, impatient, or anxiousI get tired a few hours after eatingMy memory and concentration are poorI am tired most of the timeI have extra weight around the middleI have high blood pressureI have type 2 diabetesI have a family history of diabetes
Fatty Acid
I have soft, cracked or brittle nailsI have dry, itchy, scaling, or flaking skinI have dandruffI feel aching or stiffness in my jointsI am thirsty most of the timeI have fewer than two bowel movements a dayI have light-colored, hard, or foul smelling stoolsI have poor mood, difficulty paying attention, and/or memory lossI have fibrocystic breastsI have premenstrual syndromeI have a family history of high LDL and/or low cholesterol, and high trigyyceridesI am of North Atlantic genetic background (Irish, Scottish, Welsh, Scandinavian, or coastal Native American)
Inflammation
I have seasonal or environmental allergiesI feel poorly after eating (sluggishness, headaches, congestion, confusion, phlegm)I work in an environment with poor lighting, chemicals, and poor ventilationI get frequent colds or infectionsI have a history of chronic infections (skin infections, canker sores, cold sores)I have allergies or get sinusitisI have asthmaI have arthritisI have dermatitis (eczema, acne, rashes)I have an auto-immune condition (fibromyalgia, rheumatoid arthritis, lupus)I have colitis or inflammatory bowel diseaseI 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 urineI rarely break into a real sweatI drink unfiltered tap waterI get my clothes dry cleaned frequentlyI 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