Nutritional Assessment Form

PART I

Read the following questions and fill in the number that applies:

KEY:

0 (or leave blank) = Do not consume or use
2 = Consume or use weekly
1 = Consume or use 2-3 times/month
3 = Consume or use daily

Diet

Alcohol

Artificial sweeteners

Candy or other sweets

Carbonated beverages

Chewing tobacco

Cigarettes

Cigars/pipes

Coffee

Eat fast food regularly

Fried foods

Luncheon meats/ hot dogs

Margarine

Milk products

Non-herbal tea

Refined flour/ Baked goods

Refined sugar

Vitamins and minerals

Water, distilled

Water, Tap

Water, well

Diet often

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have the symptom, the symptom does not occur
1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)
2 = It is a moderate symptom or it occasionally occurs (weekly)
3 = It is a severe symptom or it frequently occurs (daily)

Section 1 – Upper Gastrointestinal System

Belching or gas within 1 hr. of a meal

Heartburn or acid reflux

Bloating shortly after eating

Are you a vegan (no dairy, meat, fish or eggs)

Bad breath (halitosis)

Loss of taste for meat

Sweat has a strong odor

Stomach upset by taking vitamins

Sense of excess fullness after meals

Do you feel like skipping breakfast?

Do you 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 stools

Undigested food in stool

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 2 – Liver and Gallbladder

Pain between shoulder blades

Stomach upset by greasy foods

Greasy or shiny stools

Nausea

Sea, car or airplane sickness, motion sickness

History of morning sickness

Light or clay colored stools

Dry skin, itchy feet and/or skin peels on feet

Headache over the eye

Gallbladder attacks (past or present)

Gallbladder removed

Bitter taste in mouth, especially after meals

Become sick if drinking wine

If drinking alcohol, easily intoxicated

Alcoholic beverages per week

Recovering alcoholic

Hangovers after drinking alcohol

History of drug or alcohol abuse

History of hepatitis

Long term use of prescription medications

Sensitive to chemicals (perfume, cleaning solvents, insecticides, exhaust, etc.)

Sensitive to tobacco smoke

Exposure to diesel fumes

Pain under right side of rib cage

Hemorrhoids or varicose veins

Nutrasweet (aspartame) consumption

Bothered by aspartame (Nutrasweet)

Chronic fatigue or Fibromyalgia

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 3 – Small Intestine

Food allergies

Abdominal bloating 1 to 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

Wheat or grain sensitivity

Dairy sensitivity

Are there foods you could not give up

Asthma, sinus infections, stuffy nose

Bizarre vivid or nightmarish dreams

Recovering alcoholic

Hangovers after drinking alcohol

Use over-the-counter pain medications

Feel spacey or unreal

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 4 – Large Intestine

Anus itches

Coated tongue

Feel worse in moldy or musty place

Taken any antibiotic for a combined time of

Fungus or yeast infections

Ring worm, "jock itch", "athletes foot", nail fungus

Eating sugar, starch or drinking alcohol increases yeast symptoms

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 shaped

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 outer sides of thighs (Iliotibial Band)

Cramping in lower abdominal region

Dark circles under eyes

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 5 – Mineral Needs

History of Carpal Tunnel Syndrome

History of lower right abdominal pain

History of stress fractures

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

Have you ever had a 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

Vomiting or nausea

Crave chocolate

Feet have a strong odor

Tendency to anemia

Whites of eyes (sclera) blue tinted

Hoarseness

Difficulty swallowing

Lump in throat

Dry mouth, eyes and / or nose

White spots on fingernails

Cuts heal slowly and / or scar easily

Decreased sense of taste or smell

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 8 – Vitamin Need

Aspirin is an effective pain reliever

Crave fatty or greasy foods

Low or reduced fat diet (past or present)

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 and or dandruff

Section 7 – Sugar Handling

Awaken a few hours after falling asleep, hard to get back to sleep

Crave sweets

Eat desserts or sugary snacks

Excessive appetite

Crave coffee or sugar in the afternoon

Sleepy in 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

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 8 – Essential Fatty Acids

Muscles become easily fatigued

Feel worse, sore after moderate exercise

Vulnerable to insect bites

Loss of muscle tone, heaviness in arms / legs

Enlarged heart, or heart failure

Pulse slow / below 65

Ringing in the ears / Tinnitus

Numbness, tingling or itching in extremities

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

Cheilosis (cracks at corner of mouth)

Fragile skin, easily chaffed, as in shaving

Polyps or warts

MSG sensitivity

Wake up without remembering dreams

Take birth control pills

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

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 9 – Adrenal

Tend to be a "night person"

Difficulty falling asleep

Slow starter in the morning

Keyed up, trouble calming down

High blood pressure (normal 120/80)

Headache after exercising

Feeling wired or jittery if drinking coffee

Clench or grind teet

Calm on the outside, troubled inside

Chronic low back pain, worse with fatigue

Become dizzy when standing up suddenly

Difficult maintaining manipulative correction

Pain after manipulative correction

Arthritic tendencies

Crave salty foods

Salt foods before tasting

Perspire easily

Chronic fatigue, or get drowsy often

Afternoon yawning

Afternoon headache

Asthma, wheezing or difficulty breathing

Pain on the medial or inner side of the knee

Tendency to sprain ankles or "shin splints"

Allergies and / or hives

Weakness, dizziness

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 10 – Pituitary

Over 6' 6" tall (Mature height)

Early sexual development (before age 10)

Increased libido

Splitting type headache

Memory failing

Ability to tolerate sugar

Under 4' 10" (Mature height)

Decreased libido

Abnormal thirst

Weight gain around hips or waist

Menstrual disorders

Delayed (after age 13) sexual development

Tendency to ulcers or colitis

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 11 – Thyroid

Allergic to iodine

Difficulty gaining weight, even with large appetite

Nervous, emotional, can't work under pressure

Inward trembling

Flush easily

Fast pulse at rest

Intolerance to high temperatures

Difficulty losing weight

Mentally sluggish, reduced initiative

Easily fatigued, sleepy during the day

Sensitive to cold, poor circulation (cold hands and feet)

Constipation, chronic

Excessive hair loss and / or coarse hair

Morning headaches, wear off during the day

Loss of lateral 1/3 of eyebrow

Seasonal sadness

Section 12 – Men Only

Prostate problem

Urination difficult or dribbling

Difficult to start and stop urine stream

Pain or burning with urination

Waking to urinate at night

Interruption of stream during urination

Pain on inside of legs or heels

Feeling of incomplete bowel evacuation

Decreased sexual function

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 13 – Women Only

Depression during periods

Mood swings associated with periods (PMS)

Crave chocolate around periods

Breast tenderness associated with cycle

Excessive menstrual flow

Scanty blood flow during periods

Occasional skipped periods

Variations in menstrual cycles

Endometriosis

Uterine fibroids

Breast fibroids, benign masses

Painful intercourse (dyspareunia)

Vaginal discharge

Vaginal dryness

Vaginal itchiness

Gain weight around hips, thighs and buttocks

Excess facial or body hair

Hot flashes

Night sweats (in menopausal females)

Thinning skin

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 14 – Cardiovascular

Aware of heavy and / or irregular breathing

Discomfort at high altitudes

"Air hunger" and / or yawn frequently

Compelled to open windows in a closed room

Shortness of breath with moderate exertion

Ankles swell, especially at end of day

Cough at night

Blush or face turns red for no reason

Dull pain or tightness in chest and / or radiate into right arm,worse with exertion

Muscle cramps with exertion

Section 15 – Kidney and Bladder

Pain in mid back region

Dark circles under eyes and / or puffy eyes

History of kidney stones

Cloudy, bloody or darkened urine

Urine has a strong odor

PART II

Read the following questions and fill in the number that applies:

( How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

0 (or leave blank) = No or Do not have symptom, symptom does not occur
1 = Yes or Minor or mild symptom (once a month or less)
2 = Moderate symptom, occurs occasionally (weekly)
3 = Severe symptom, frequently occurs (daily)

Section 16 – Immune system

Runny or drippy nose

Catch colds at the beginning of winter

Mucus producing coughy

Frequent infections (ear, sinus, lung, skin, bladder, kidney, etc.)

Frequent colds or flu

Never get

Acne (adult)

Itchy skin / dermatitis

Cysts, boils, rashes

History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue, Hepatitis or other chronic viral condition

Name

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