Nutritional Assessment Questionnaire
Name:
Date:
Birth Date:
Gender:
/
/
Please list your five major health concerns in order of importance:
1.
2.
3.
4.
5.
Notes:
PART I
KEY:
Read the following questions and add the number that applies, after the item(s):
0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly
2 = Consume or use weekly
3 = Consume or use daily
DIET (add the key number next to the item. Eg. Fried Foods - 2
1.
2.
3.
4.
5.
6.
Alcohol
Artificial sweeteners
Confectionary or other sweets
Fizzy drinks
Chewing tobacco
Cigarettes
7.
8.
9.
10.
11.
12.
13.
Cigars/pipes
Caffeinated beverages
Fast foods
Fried foods
Tinned meats/hot dogs
Margarine
Milk products
14.
15.
16.
17.
18.
19.
20.
Radiation exposure (0=no, 1=yes)
Refined flour/baked goods
Vitamins and minerals
Water, distilled
Water, tap
Water, bottled mineral water
Diet often for weight control
LIFESTYLE – add the key number next to the description. Eg. Changed jobs - 3
21.
22.
23.
24.
Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a month)
Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
MEDICATIONS
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
Indicate any medications you’re cu rrently taking or have taken in the last month (0=no, 1=yes):
Antacids
Antianxiety medications
Antibiotics
Anticonvulsants
Antidepressants
Antifungals
Aspirin/Ibuprofen/Paracetamol
Asthma inhalers
Beta blockers
Birth control pills/implant contraceptives
Chemotherapy
Cholesterol lowering medications
Cortisone/steroids
Diabetic medications/insulin
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Diuretics
Oestrogen or progesterone
(pharmaceutical,prescription)
Oestrogen or progesterone (natural)
Heart medications
High blood pressure medications
Laxatives
Recreational drugs
Relaxants/Sleeping pills
Testosterone (natural or prescription)
Thyroid medication
Acetaminophen (Tylenol)
Ulcer medications
Sildenafal citrate (Viagra)
PART II (See key at bottom of page)
Section 1
52.
53.
54.
55.
56.
57.
58.
59.
60.
Belching or gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (no dairy, meat, fish or eggs) (0=no, 1=yes)
Bad breath (halitosis)
Loss of taste for meat
Sweat has a strong odor
Stomach upset by taking vitamins
Sense of excess fullness after meals
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
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
Diarrhoea, chronic
Diarrhoea shortly after meals
Black or tarry colored stools
Undigested food in stool
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)
Nutritional Assessment Questionnaire
Page 2 of 4
Section 2 (See key at bottom of page)
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car, airplane or motion sickness
History of morning sickness (0 = no, 1 = yes)
Light or clay colored stools
Dry skin, itchy feet or skin peels on feet
Headache over eyes
Gallbladder attacks (0=never, 1=years ago, 2=within
last year, 3=within past 3 months)
Gallbladder removed (0=no, 1=yes)
Bitter taste in mouth, especially after meals
Become sick if you were to drink wine (0=no, 1=yes)
Easily intoxicated if you were to drink wine (0=no,
1=yes)
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
Easily hung over if you were to drink wine (0=no, 1=yes)
Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14)
Recovering alcoholic (0=no, 1=yes)
History of drug or alcohol abuse (0=no, 1=yes)
History of hepatitis (0=no, 1=yes)
Long term use of prescription/recreational drugs (0=no,
1=yes)
Sensitive to chemicals (perfume, cleaning agents,
etc.)
Sensitive to tobacco smoke
Exposure to diesel fumes
Pain under right side of rib cage
Haemorrhoids or varicose veins
Nutrasweet (aspartame) consumption
Sensitive to Nutrasweet (aspartame)
Chronic fatigue or Fibromyalgia
Section 3 (See key at bottom of page)
99.
100.
101.
102.
103.
104.
105.
106.
107.
Food allergies
Abdominal bloating 1 to 2 hours after eating
Specific foods make you tired or bloated (0=no, 1=yes)
Pulse speeds after eating
Airborne allergies
Experience hives
Sinus congestion, "stuffy head"
Crave bread or noodles
Alternating constipation and diarrhoea
108.
109.
110.
111.
112.
113.
114.
115.
Crohn's disease (0 =no, 1=yes in the past,
2=currently mild condition, 3=severe)
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up (0=no, 1=yes)
Asthma, sinus infections, stuffy nose
Bizarre vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal
Section 4 (See key at bottom of page)
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
Anus itches
Coated tongue
Feel worse in mouldy or musty place
Taken antibiotic for a total accumulated time of
(0=never, 1= <1 month, 2= <3 months, 3= >3
months)
Fungus or yeast infections
Ring worm, "jock itch", "athletes foot", nail fungus
Yeast symptoms increase with sugar, starch or alcohol
Stools hard or difficult to pass
History of parasites (0=no, 1=yes)
Less than one bowel movement per day
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
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 odours
Painful to press along outer sides of thighs (Iliotibial
Band)
Cramping in lower abdominal region
Dark circles under eyes
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
History of bone spurs (0=no, 1=yes)
Morning stiffness
Nausea with vomiting
Crave chocolate
Feet have a strong odour
History of anaemia
Whites of eyes (sclera) blue tinted
Hoarseness
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
Section 5 (See key at bottom of page)
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
History of carpal tunnel syndrome (0=no, 1=yes)
History of lower right abdominal pains or ileocecal
valve problems (0=no, 1=yes)
History of stress fracture (0=no, 1=yes)
Bone loss (reduced density on bone scan)
Are you shorter than you used to be? (0=no, 1=yes)
Calf, foot or toe cramps at rest
Cold sores, fever blisters or herpes lesions
Frequent fevers
Frequent skin rashes and/or hives
Herniated disc (0=no, 1=yes)
Excessively flexible joints, "double jointed"
Joints pop or click
Pain or swelling in joints
Bursitis or tendonitis
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)
Nutritional Assessment Questionnaire
Page 3 of 4
Section 6 (See key at bottom of page)
165.
166.
167.
168.
Experience pain relief with aspirin (0=no, 1=yes)
Crave fatty or greasy foods
Low- or reduced-fat diet (0=never, 1=years ago, 2=within
Last year, 3=currently)
Tension headaches at base of skull
169.
170.
171.
172.
Headaches when out in the hot sun
Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff
180.
181.
182.
183.
184.
185.
Headache if meals are skipped or delayed
Irritable before meals
Shaky if meals delayed
Family members with diabetes (0=none, 1=1 or 2, 2=3 or
4, 3=more than 4)
Frequent thirst
Frequent urination
200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
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 (Cheilosis)
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
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
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"
Tendency to need sunglasses
Allergies and/or hives
Weakness, dizziness
245.
246.
247.
248.
249.
250.
Height under 4' 10" (0=no, 1=yes)
Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders
Delayed sexual development (after age 13) (0=no,
1=yes)
Tendency to ulcers or colitis
Section 7 (See key at bottom of page)
173.
174.
175.
176.
177.
178.
179.
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 afternoon
Fatigue that is relieved by eating
Section 8 (See key at bottom of page)
186.
187.
188.
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.
Muscles become easily 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 (0=no, 1=yes)
Ringing in the ears (Tinnitus)
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier, apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart races
Section 9 (See key at bottom of page)
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
Tend to be a "night person"
Difficulty falling asleep
Slow starter in the morning
Tend to be keyed up, trouble calming down
Blood pressure above 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calm on the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction (eg osteopathy)
Section 10 (See key at bottom of page)
239.
240.
241.
242.
243.
244.
Height over 6' 6" (0=no, 1=yes)
Early sexual development (before age 10) (0=no, 1=yes)
Increased libido
Splitting type headache
Memory failing
Tolerate sugar, feel fine when eating sugar (0=no,
1=yes)
251.
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)
Nutritional Assessment Questionnaire
Page 4 of 4
Section 11 (See key at bottom of page)
252.
253.
254.
255.
256.
257.
258.
259.
Sensitive/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
260.
261.
262.
263.
264.
265.
266.
267.
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
272.
273.
274.
275.
276.
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
287.
288.
289.
290.
291.
292.
293.
294.
295.
296.
Breast fibroids, benign masses
Painful intercourse (dysparenia)
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
302.
303.
304.
305.
306.
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
310.
311.
Cloudy, bloody or darkened urine
Urine has a strong odor
317.
Never get sick (0 = sick only 1 or 2 times in last 2 years,
1 = not sick in last 2 years, 2 = not sick in last
4 years, 3 = not sick in last 7 years)
Acne (adult)
Itchy skin (Dermatitis)
Cysts, boils, rashes
History of Epstein Bar, Mono, Herpes,
Shingles, Chronic Fatigue Syndrome, Hepatitis
or other chronic viral condition (0 = no, 1 = yes
in the past, 2 = currently mild condition, 3 =
severe)
Section 12 – Men Only (See key at bottom of page)
268.
269.
270.
271.
Prostate problems
Difficulty with urination, dribbling
Difficult to start and stop urine stream
Pain or burning with urination
Section 13 – Women Only (See key at bottom of page)
277.
278.
279.
280.
281.
282.
283.
284.
285.
286.
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
Section 14 (See key at bottom of page)
297.
298.
299.
300.
301.
Aware of heavy and/or irregular breathing
Discomfort at high altitudes
"Air hunger" or sigh frequently
Compelled to open windows in a closed room
Shortness of breath with moderate exertion
Section 15 (See key at bottom of page)
307.
308.
309.
Pain in mid-back region
Puffy around the eyes, dark circles under eyes
History of kidney stones (0=no, 1=yes)
Section 16 (See key at bottom of page)
312.
313.
314.
315.
316.
Runny or drippy nose
Catch colds at the beginning of winter
Mucus producing cough
Frequent colds or flu (0=1 or less per year, 1=2 to 3 times
per year, 2=4 to 5 times per year, 3=6 or more
times per year)
Other infections (sinus, ear, lung, skin, bladder, kidney,
etc.) (0=1 or less per year, 1=2 to 3 times per
year, 2=4 to 5 times per year, 3=6 or more
times per year)
318.
319.
320.
321.
NOTES:
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)