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Nutritional Assessment Questionnaire
Name:
Date:
PART I
Read the following questions and type the number that applies next to each item:
KEY: Blank = Do not consume or use
2 = Consume or use weekly
1 = Consume or use 2 to 3 times monthly
3 = Consume or use daily
DIET
Alcohol
7.
Artificial sweeteners
8.
Candy, desserts, sugars
9.
Carbonated beverages
10.
Chewing tobacco 11.
Cigarettes
12.
13.
58
Cigars/pipes
14.
Caffeinated beverages
15.
Fast foods 16.
Fried foods 17.
Luncheon meats
18.
Margarine 19.
Milk products 20.
Radiation exposure (1=yes)
Refined flour/baked goods
Vitamins and minerals
Water, distilled
Water, tap
Water, well
Diet often for weight control
Typical Example of Each of the Following:
Breakfast:
Lunch:
Dinner:
Snacks:
Fluids: (type and amount)
Mark any medications you’re currently taking or have taken in the last month (Blank = no, 1 = yes): 54
25.
Antacids
39.
Diuretics
Antianxiety medications
40.
Estrogen or progesterone (pharmaceutical,
Antibiotics
prescription)
Anticonvulsants
41.
Estrogen or progesterone (natural)
Antidepressants
42.
Heart medications
Antifungals
43.
High blood pressure medications
Aspirin/Ibuprofen
44.
Laxatives
Asthma inhalers
45.
Recreational drugs
Beta blockers
46.
Relaxants/Sleeping pills
Birth control pills/implant contraceptives
47.
Testosterone (natural or prescription)
Chemotherapy
48.
Thyroid medication
Cholesterol lowering medications
49.
Acetaminophen (Tylenol)
Cortisone/steroids
50.
Ulcer medications
Diabetic medications/insulin
51.
Sildenafal citrate (Viagra)
PART II
(If Never Occurs, Leave Blank . Otherwise Mark 1= Yes but rare/monthly, 2=Yes weekly, 3= Yes daily)
Section 1
Belching or gas within one hour after64.eating
Heartburn or acid reflux
65.
Bloating or fullness within 1 hour after
66.eating
Vegan diet
67.
Bad breath (halitosis)
68.
Loss of taste for meat
69.
Sweat has a strong odor
70.
Stomach upset by taking vitamins 71.
Sense of excess fullness after meals72.
Feel like skipping breakfast
73.
Feel better if you don’t eat
74.
Sleepy after meals
75.
Section 2
76.
Pain between shoulder blades
90.
Stomach upset by greasy foods
Greasy or shiny stools
91.
Yellowish cast to eyes
Nausea
92.
Sea, car, airplane or motion sickness
93.
History of morning sickness (1 = yes)
94.
Light or clay colored stools
95.
Dry skin, itchy feet or skin peels on feet
Headache over eyes
96.
Gallbladder attacks (1= yes)
Gallbladder removed (1=yes)
97.
88.
Bitter or metallic taste in mouth, especially
98.
after meals or in morning
99.
89.
Become sick or easily intoxicated if100.
you
were to drink wine (1=yes)
101.
102.
103.
101.
Section 3
Food allergies
108.
Abdominal bloating 2 to 4 hours after
109. eating
Specific foods make you tired or bloated
110.
(1=yes)
111.
Pulse speeds after eating
Airborne allergies
112.
Experience hives
113.
Sinus congestion, "stuffy head" 114.
Crave bread or noodles
115.
Alternating constipation and diarrhea
116.
67
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
Stomach pain 1-4 hours after eating
Stomach pain relieved from food, milk,
carbonated drinks
Digestive problems subside with relaxation
Heartburn specifically due to spicy food,
citrus, alcohol, caffeine
68
Easily hung over if you were to drink wine
(blank=no, 1=yes)
Alcohol per week (blank=<3, 1=<7, 2 =<14,
3=>14)
Recovering alcoholic (blank=no, 1=yes)
History of drug or alcohol abuse (1 = yes)
History of hepatitis (1=yes)
Long term use of prescription/recreational
drugs (1=yes)
Sensitive to chemicals (perfume, cleaning
agents, etc.)
Sensitive to tobacco smoke
Exposure to diesel fumes
Pain under right side of rib cage
Hemorrhoids or varicose veins
Nutrasweet (aspartame) consumption
Sensitive to Nutrasweet (aspartame)
Chronic fatigue or Fibromyalgia
52
Roughage/Fiber cause gas or constipation
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up
(1=yes)
Asthma, sinus infections, stuffy nose
Bizarre vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal
Stool floats
120.
Section 4
Anus itches
128.
Coated or “fuzzy” tongue
129.
Feel worse in moldy or musty place 130.
Taken antibiotic for a total accumulated
131.time of
(1= <1 month, 2= <3 months, 3= >3132.
months)
Fungus or yeast infections
133.
"jock itch", "athletes foot", nail fungus134.
Yeast symptoms with sugar, starch or135.
alcohol
Stools hard or difficult to pass
136.
History of parasites (1=yes)
137.
Less than one bowel movement per day
138.
Alternating diarrhea and constipation
Section 5
History of carpal tunnel syndrome (1=yes)
150.
History of lower right abdominal pains151.
(1= yes)
History of stress fracture (1=yes)
152.
Bone loss (reduced density on bone scan)
153.
Are you shorter than you used to be?154.
(1=yes)
Calf, foot or toe cramps at rest
155.
Cold sores, fever blisters or herpes lesions
156.
Frequent fevers
157.
Frequent skin rashes and/or hives 158.
Herniated disc (1=yes)
159.
Excessively flexible joints, "double jointed"
160.
Joints pop or click
161.
Pain or swelling in joints
162.
Bursitis or tendonitis
163.
164.
167.
Section 6
Experience pain relief with aspirin169.
(1=yes)
Crave fatty or greasy foods
170.
Low- or reduced-fat diet (blank=never,
171.
1=years ago, 2=within past year,
172.
3=currently)
Tension headaches at base of skull
64
Stools 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
Cramping in lower abdominal region
Dark circles under eyes
Feeling that bowels do not completely empty
More than 3 bowel movements per day
75
History of bone spurs (1=yes)
Morning stiffness
Nausea with vomiting
Crave chocolate
Feet have a strong odor
History of anemia
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
22
Headaches when out in the hot sun
Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff
173.
Section 7
Awaken a few hours after falling asleep,
181.
hard to get back to sleep
182.
Crave sweets during the day
Binge or uncontrolled eating
183.
Excessive appetite
184.
Need coffee or sugar to keep yourself
185. going
Sleepy in afternoon
186.
Fatigue that is relieved by eating 187.
Headache if meals are skipped or delayed
Section 8
21
Fatigue after meals
193.
Eating sweets doesn’t relieve sugar
194.cravings
Must have sweets after meals 195.
Raised cholesterol
196.
High Blood Pressure
Section 9
Muscles become easily fatigued 212.
Feel exhausted or sore after mild213.
or
moderate exercise
214.
Vulnerable to insect bites
215.
Loss of muscle tone, heaviness in216.
arms/legs
Enlarged heart or congestive heart
217.
failure
Pulse below 65 per minute (0=no,218.
1=yes)
Ringing in the ears (Tinnitus)
219.
Numbness, tingling or itching in hands
220. and
feet
221.
Depressed
222.
Fear of impending doom
223.
Worrier, apprehensive, anxious 224.
Nervous or agitated
225.
Feelings of insecurity
Heart races
Section 10
Tend to be a "night person"
228.
Difficulty falling asleep
229.
Tend to be keyed up, trouble calming
230. down
Blood pressure above 120/80
231.
Headache after exercising
232.
Clench or grind teeth
233.
Calm on the outside, troubled on 234.
the inside
Perspire easily even with little or 235.
no activity
Under high amounts of stress
236.
Weight gain when under stress 237.
Wake up tired even after 6 or more
238.
hours
sleep
239.
Slow starter in the morning
240.
Feeling wired or jittery after drinking
241.coffee
Chronic low back pain, worse with242.
fatigue
243.
45
Irritable before meals or if meal is skipped
Shaky or lightheaded especially if meals are
delayed or missed
Nervous, easily upset or agitated
Family members with diabetes
Frequent thirst
Frequent urination
Poor Memory, Forgetful
Waist girth equal to or greater than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
78
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
84
Become dizzy when standing up suddenly
Difficulty maintaining chiropractic
adjustment
Pain after manipulative correction
Arthritic tendencies
Crave salty foods
Salt foods before tasting
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
Section 11
239.
Early sexual development (before245.
age 10)
(1=yes)
246.
Increased libido
247.
Splitting type headache
248.
Memory failing
249.
Reduced sugar tolerance (1= yes)
Tolerate sugar well (1=yes)
250.
Section 12
Sensitive/allergic to iodine
266.
Difficulty gaining weight, even with large
267.
appetite
Nervous, emotional, can't work under
268.
pressure
269.
Inward trembling
270.
Flush easily
271.
Fast pulse at rest or heart palpitations
272.
Intolerance to high temperatures
273.
Insomnia
Night Sweats
274.
Difficulty losing weight
Mentally sluggish, depressed or lack of
motivation
Section 12 – Men Only
Prostate problems
279.
Difficulty with urination, dribbling
280.
Difficult to start and stop urine stream
281.
Pain or burning with urination
282.
Frequent urination
283.
Waking to urinate at night
284.
Interruption of stream during urination
285.
Pain on inside of legs or heels 286.
Feeling of incomplete bowel evacuation
287.
Decreased sexual function
288.
Decreased libido
289.
290.
291.
25
Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders or lack of menstruation
Delayed sexual development (after age 13)
(1=yes)
Tendency to ulcers or colitis
54
Easily fatigued, sleepy during the day
Sensitive to cold, poor circulation, feel cold
hands, feet or all over
Chronic problems with constipation
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the
day
Loss of or thinning of outer 1/3 of eyebrow
Thinning hair on scalp, face, genitals, or
excess hair loss
Dryness of skin and/or scalp
63
Decrease in spontaneous morning
erections
Decrease in fullness of erections
Mental fatigue
Inability to concentrate
Spells of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increased fat distribution in chest and/or
hips
Sweating attacks
More emotional than in past
292.
293.
294.
295.
296.
297.
298.
299.
300.
301.
302.
303.
304.
Section 13 – Women Only
Menstruating Women
42
Menopausal Postmenopausal Women
Depression during periods
305.
Mood swing associated with periods (PMS)
306.
Crave chocolate around periods
307.
Breast tenderness associated with cycle308.
Excessive menstrual flow
309.
Scanty blood flow during periods
310.
Pain and cramping during periods
311.
Occasional skipped periods
312.
Variations in menstrual cycle lengths 313.
Endometriosis
314.
Uterine fibroids
315.
Breast fibroids, benign masses
316.
Excess facial or body hair
317.
Acne breakouts with menstrual cycle 318.
Hair loss, thinning hair
319.
Section 14
Aware of heavy and/or irregular 303.
breathing
Discomfort at high altitudes
304.
"Air hunger" or sigh frequently 305.
Compelled to open windows in a closed306.
room
Shortness of breath with moderate
307.exertion
Section 15
Pain in mid-back region
311.
Puffy around the eyes, dark circles
312.under
eyes
History of kidney stones (1=yes)
Section 16
Runny or drippy nose
319.
Catch colds at the beginning of winter
320.
Mucus producing cough
321.
Frequent colds or flu (1 = yes) 322.
Other frequent infections (sinus, ear, lung,
323.
skin, bladder, kidney, etc.) (1 = yes) 324.
325.
42
Excess facial or body hair
Thinning skin
Hair loss, thinning hair
Hot flashes
Painful intercourse
Vaginal discharge
Vaginal dryness
Vaginal itchiness
Decreased libido
Mood swings
Night sweats (in menopausal females)
Mental fogginess
Depression
Shrinking breasts
Bleeding following menopause (1=no)
27
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
13
Cloudy, bloody or darkened urine
Urine has a strong odor
30
Never get sick
Acne (adult)
Itchy skin (Dermatitis)
Cysts, boils, rashes
History of Epstein Bar, Mono, Herpes,
Shingles, or