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Nutritional Assessment Questionnaire

Please note that this form has 16 sections and 321 questions. Please scroll down to the bottom to make sure all sections are available before completing the form.

PART I: Read the following questions and circle the number that applies: DIET: 1. Alcohol
DIET: 2. Artificial sweeteners
DIET: 3. Candy, desserts, refined sugar
DIET: 4. Carbonated beverages
DIET: 5. Chewing tobacco
DIET: 6. Cigarettes
DIET: 7. Cigars/pipes
DIET: 8. Caffeinated beverages
DIET: 9. Fast foods
DIET: 10. Fried foods
DIET: 11. Luncheon meats
DIET: 12. Margarine
DIET: 13. Milk products
DIET: 14. Radiation exposure
DIET: 15. Refined flour/baked goods
DIET: 16. Vitamins and minerals
DIET: 17. Water, distilled
DIET: 18. Water, tap
DIET: 19. Water, well
DIET: 20. Diet often for weight control
LIFESTYLE: 21. Exercise per week
LIFESTYLE: 22. Changed jobs
LIFESTYLE: 23. Divorced
LIFESTYLE: 24. Work over 60 hours/week
MEDICATIONS: 25. Antacids Indicate any medications you’re currently taking or have taken in the last month.
MEDICATIONS: 26. Antianxiety medications
MEDICATIONS: 27. Antibiotics
MEDICATIONS: 28. Anticonvulsants
MEDICATIONS: 29. Antidepressants
MEDICATIONS: 30. Antifungals
MEDICATIONS: 31. Aspirin/Ibuprofen
MEDICATIONS: 32. Asthma inhalers
MEDICATIONS: 33. Beta blockers
MEDICATIONS: 34. Birth control pills/implant contraceptives
MEDICATIONS: 35. Chemotherapy
MEDICATIONS: 36. Cholesterol lowering medications
MEDICATIONS: 37. Cortisone/steroids
MEDICATIONS: 38. Diabetic medications/insulin
MEDICATIONS: 39. Diuretics
MEDICATIONS: 40. Estrogen or progesterone (pharmaceutical, prescription)
MEDICATIONS: 41. Estrogen or progesterone (natural)
MEDICATIONS: 42. Heart medications
MEDICATIONS: 43. High blood pressure medications
MEDICATIONS: 44. Laxatives
MEDICATIONS: 45. Recreational drugs
MEDICATIONS: 46. Relaxants/Sleeping pills
MEDICATIONS: 47. Testosterone (natural or prescription)
MEDICATIONS: 48. Thyroid medication
MEDICATIONS: 49. Acetaminophen (Tylenol)
MEDICATIONS: 50. Ulcer medications
MEDICATIONS: 51. Sildenafal citrate (Viagra)
Part 2: Section 1: 52. Belching or gas within one hour after eating
Section 1: 53. Heartburn or acid reflux
Section 1: 54. Bloating within one hour after eating
Section 1: 55. Vegan diet (no dairy, meat, fish or eggs)
Section 1: 56. Bad breath (halitosis)
Section 1: 57. Loss of taste for meat
Section 1: 58. Sweat has a strong odor
Section 1: 59. Stomach upset by taking vitamins
Section 1: 60. Sense of excess fullness after meals
Section 1: 61. Feel like skipping breakfast
Section 1: 62. Feel better if you don’t eat
Section 1: 63. Sleepy after meals
Section 1: 64. Fingernails chip, peel or break easily
Section 1: 65. Anemia unresponsive to iron
Section 1: 66. Stomach pains or cramps
Section 1: 67. Diarrhea, chronic
Section 1: 68. Diarrhea shortly after meals
Section 1: 69. Black or tarry colored stools
Section 1: 70. Undigested food in stool
Section 2: 71. Pain between shoulder blades
Section 2: 72. Stomach upset by greasy foods
Section 2: 73. Greasy or shiny stools
Section 2: 74. Nausea
Section 2: 75. Sea, car, airplane or motion sickness
Section 2: 76. History of morning sickness
Section 2: 77. Light or clay colored stools
Section 2: 78. Dry skin, itchy feet or skin peels on feet
Section 2: 79. Headache over eyes
Section 2: 80. Gallbladder attacks
Section 2: 81. Gallbladder removed
Section 2: 82. Bitter taste in mouth, especially after meals
Section 2: 83. Become sick if you were to drink wine
Section 2: 84. Easily intoxicated if you were to drink wine
Section 2: 85. Easily hung over if you were to drink wine
Section 2: 86. Alcohol per week
Section 2: 87. Recovering alcoholic
Section 2: 88. History of drug or alcohol abuse
Section 2: 89. History of hepatitis
Section 2: 90. Long term use of prescription/recreational drugs
Section 2: 91. Sensitive to chemicals (perfume, cleaning agents, etc.)
Section 2: 92. Sensitive to tobacco smoke
Section 2: 93. Exposure to diesel fumes
Section 2: 94. Pain under right side of rib cage
Section 2: 95. Hemorrhoids or varicose veins
Section 2: 96. Nutrasweet (aspartame) consumption
Section 2: 97. Sensitive to Nutrasweet (aspartame)
Section 2: 98. Chronic fatigue or Fibromyalgia
Section 3: 99. Food allergies
Section 3: 100. Abdominal bloating 1 to 2 hours after eating
Section 3: 101. Specific foods make you tired or bloated
Section 3: 102. Pulse speeds after eating
Section 3: 103. Airborne allergies
Section 3: 104. Experience hives
Section 3: 105. Sinus congestion, “stuffy head”
Section 3: 106. Crave bread or noodles
Section 3: 107. Alternating constipation and diarrhea
Section 3: 108. Crohn’s disease
Section 3: 109. Wheat or grain sensitivity
Section 3: 110. Dairy sensitivity
Section 3: 111. Are there foods you could not give up
Section 3: 112. Asthma, sinus infections, stuffy nose
Section 3: 113. Bizarre vivid dreams, nightmares
Section 3: 114. Use over-the-counter pain medications
Section 3: 115. Feel spacey or unreal
Section 4: 116. Anus itches
Section 4: 117. Coated tongue
Section 4: 118. Feel worse in moldy or musty place
Section 4: 119. Taken antibiotic for a total accumulated time of
Section 4: 120. Fungus or yeast infections
Section 4: 121. Ring worm, “jock itch”, “athletes foot”, nail fungus
Section 4: 122. Yeast symptoms increase with sugar, starch or alcohol
Section 4: 123. Stools hard or difficult to pass
Section 4: 124. History of parasites
Section 4: 125. Less than one bowel movement per day
Section 4: 126. Stools have corners or edges, are flat or ribbon shaped
Section 4: 127. Stools are not well formed (loose)
Section 4: 128. Irritable bowel or mucus colitis
Section 4: 129. Blood in stool
Section 4: 130. Mucus in stool
Section 4: 131. Excessive foul smelling lower bowel gas
Section 4: 132. Bad breath or strong body odors
Section 4: 133. Painful to press along outer sides of thighs (Iliotibial Band)
Section 4: 134. Cramping in lower abdominal region
Section 4: 135. Dark circles under eyes
Section 5: 136. History of carpal tunnel syndrome
Section 5: 137. History of lower right abdominal pains or ileocecal valve problems
Section 5: 138. History of stress fracture
Section 5: 139. Bone loss (reduced density on bone scan)
Section 5: 140. Are you shorter than you used to be?
Section 5: 141. Calf, foot or toe cramps at rest
Section 5: 142. Cold sores, fever blisters or herpes lesions
Section 5: 143. Frequent fevers
Section 5: 144. Frequent skin rashes and/or hives
Section 5: 145. Herniated disc
Section 5: 146. Excessively flexible joints, “double jointed”
Section 5: 147. Joints pop or click
Section 5: 148. Pain or swelling in joints
Section 5: 149. Bursitis or tendonitis
Section 5: 150. History of bone spurs
Section 5: 151. Morning stiffness
Section 5: 152. Nausea with vomiting
Section 5: 153. Crave chocolate
Section 5: 154. Feet have a strong odor
Section 5: 155. History of anemia
Section 5: 156. Whites of eyes (sclera) blue tinted
Section 5: 157. Hoarseness
Section 5: 158. Difficulty swallowing
Section 5: 159. Lump in throat
Section 5: 160. Dry mouth, eyes and/or nose
Section 5: 161. Gag easily
Section 5: 162. White spots on fingernails
Section 5: 163. Cuts heal slowly and/or scar easily
Section 5:164. Decreased sense of taste or smell
Section 6: 165. Experience pain relief with aspirin
Section 6: 166. Crave fatty or greasy foods
Section 6: 167. Low- or reduced-fat diet
Section 6: 168. Tension headaches at base of skull
Section 6: 169. Headaches when out in the hot sun
Section 6: 170. Sunburn easily or suffer sun poisoning
Section 6: 171. Muscles easily fatigued
Section 6: 172. Dry flaky skin or dandruff
Section 7: 173. Awaken a few hours after falling asleep, hard to get back to sleep
Section 7: 174. Crave sweets
Section 7: 175. Binge or uncontrolled eating
Section 7: 176. Excessive appetite
Section 7: 177. Crave coffee or sugar in the afternoon
Section 7: 178. Sleepy in afternoon
Section 7: 179. Fatigue that is relieved by eating
Section 7: 180. Headache if meals are skipped or delayed
Section 7: 181. Irritable before meals
Section 7: 182. Shaky if meals delayed
Section 7: 183. Family members with diabetes
Section 7: 184. Frequent thirst
Section 7: 185. Frequent urination
Section 8: 186. Muscles become easily fatigued
Section 8: 187. Feel exhausted or sore after moderate exercise
Section 8: 188. Vulnerable to insect bites
Section 8: 189. Loss of muscle tone, heaviness in arms/legs
Section 8: 190. Enlarged heart or congestive heart failure
Section 8: 191. Pulse below 65 per minute
Section 8: 192. Ringing in the ears (Tinnitus)
Section 8: 193. Numbness, tingling or itching in hands and feet
Section 8: 194. Depressed
Section 8: 195. Fear of impending doom
Section 8: 196. Worrier, apprehensive, anxious
Section 8: 197. Nervous or agitated
Section 8: 198. Feelings of insecurity
Section 8: 199. Heart races
Section 8: 200. Can hear heart beat on pillow at night
Section 8: 201. Whole body or limb jerk as falling asleep
Section 8: 202. Night sweats
Section 8: 203. Restless leg syndrome
Section 8: 204. Cracks at corner of mouth (Cheilosis)
Section 8: 205. Fragile skin, easily chaffed, as in shaving
Section 8: 206. Polyps or warts
Section 8: 207. MSG sensitivity
Section 8: 208. Wake up without remembering dreams
Section 8: 209. Small bumps on back of arms
Section 8: 210. Strong light at night irritates eyes
Section 8: 211. Nose bleeds and/or tend to bruise easily
Section 8: 212. Bleeding gums especially when brushing teeth
Section 9: 213. Tend to be a “night person”
Section 9: 214. Difficulty falling asleep
Section 9: 215. Slow starter in the morning
Section 9: 216. Tend to be keyed up, trouble calming down
Section 9: 217. Blood pressure above 120/80
Section 9: 218. Headache after exercising
Section 9: 219. Feeling wired or jittery after drinking coffee
Section 9: 220. Clench or grind teeth
Section 9: 221. Calm on the outside, troubled on the inside
Section 9: 222. Chronic low back pain, worse with fatigue
Section 9: 223. Become dizzy when standing up suddenly
Section 9: 224. Difficulty maintaining manipulative correction
Section 9: 225. Pain after manipulative correction
Section 9: 226. Arthritic tendencies
Section 9: 227. Crave salty foods
Section 9: 228. Salt foods before tasting
Section 9: 229. Perspire easily
Section 9: 230. Chronic fatigue, or get drowsy often
Section 9: 231. Afternoon yawning
Section 9: 232. Afternoon headache
Section 9: 233. Asthma, wheezing or difficulty breathing
Section 9: 234. Pain on the medial or inner side of the knee
Section 9: 235. Tendency to sprain ankles or “shin splints”
Section 9: 236. Tendency to need sunglasses
Section 9: 237. Allergies and/or hives
Section 9: 238. Weakness, dizziness
Section 10: 239. Height over 6′ 6″
Section 10: 240. Early sexual development (before age 10)
Section 10: 241. Increased libido
Section 10: 242. Splitting type headache
Section 10: 243. Memory failing
Section 10: 244. Tolerate sugar, feel fine when eating sugar
Section 10: 245. Height under 4′ 10″
Section 10: 246. Decreased libido
Section 10: 247. Excessive thirst
Section 10: 248. Weight gain around hips or waist
Section 10: 249. Menstrual disorders
Section 10: 250. Delayed sexual development
Section 10: 251. Tendency to ulcers or colitis
Section 11: 252. Sensitive/allergic to iodine
Section 11: 253. Difficulty gaining weight, even with large appetite
Section 11: 254. Nervous, emotional, can’t work under pressure
Section 11: 255. Inward trembling
Section 11: 256. Flush easily
Section 11: 257. Fast pulse at rest
Section 11: 258. Intolerance to high temperatures
Section 11: 259. Difficulty losing weight
Section 11: 260. Mentally sluggish, reduced initiative
Section 11: 261. Easily fatigued, sleepy during the day
Section 11: 262. Sensitive to cold, poor circulation (cold hands and feet)
Section 11: 263. Constipation, chronic
Section 11: 264. Excessive hair loss and/or coarse hair
Section 11: 265. Morning headaches, wear off during the day
Section 11: 266. Loss of lateral 1/3 of eyebrow
Section 11: 267. Seasonal sadness
Section 12 – Men Only: 268. Prostate problems
Section 12 – Men Only: 269. Difficulty with urination, dribbling
Section 12 – Men Only: 270. Difficult to start and stop urine stream
Section 12 – Men Only: 271. Pain or burning with urination
Section 12 – Men Only: 272. Waking to urinate at night
Section 12 – Men Only: 273. Interruption of stream during urination
Section 12 – Men Only: 274. Pain on inside of legs or heels
Section 12 – Men Only: 275. Feeling of incomplete bowel evacuation
Section 12 – Men Only: 276. Decreased sexual function
Section 13 – Women Only: 277. Depression during periods
Section 13 – Women Only: 278. Mood swings associated with periods (PMS)
Section 13 – Women Only: 279. Crave chocolate around periods
Section 13 – Women Only: 280. Breast tenderness associated with cycle
Section 13 – Women Only: 281. Excessive menstrual flow
Section 13 – Women Only: 282. Scanty blood flow during periods
Section 13 – Women Only: 283. Occasional skipped periods
Section 13 – Women Only: 284. Variations in menstrual cycles
Section 13 – Women Only: 285. Endometriosis
Section 13 – Women Only: 286. Uterine fibroids
Section 13 – Women Only: 287. Breast fibroids, benign masses
Section 13 – Women Only: 288. Painful intercourse (dysparenia)
Section 13 – Women Only: 289. Vaginal discharge
Section 13 – Women Only: 290. Vaginal dryness
Section 13 – Women Only: 291. Vaginal itchiness
Section 13 – Women Only: 292. Gain weight around hips, thighs and buttocks
Section 13 – Women Only: 293. Excess facial or body hair
Section 13 – Women Only: 294. Hot flashes
Section 13 – Women Only: 295. Night sweats (in menopausal females)
Section 13 – Women Only: 296. Thinning skin
Section 14: 297. Aware of heavy and/or irregular breathing
Section 14: 298. Discomfort at high altitudes
Section 14: 299. “Air hunger” or sigh frequently
Section 14: 300. Compelled to open windows in a closed room
Section 14: 301. Shortness of breath with moderate exertion
Section 14: 302. Ankles swell, especially at end of day
Section 14: 303. Cough at night
Section 14: 304. Blush or face turns red for no reason
Section 14: 305. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
Section 14: 306. Muscle cramps with exertion
Section 15: 307. Pain in mid-back region
Section 15: 308. Puffy around the eyes, dark circles under eyes
Section 15: 309. History of kidney stones
Section 15: 310. Cloudy, bloody or darkened urine
Section 15: 311. Urine has a strong odor
Section 16: 312. Runny or drippy nose
Section 16: 313. Catch colds at the beginning of winter
Section 16: 314. Mucus producing cough
Section 16: 315. Frequent colds or flu
Section 16: 316. Other infections (sinus, ear, lung, skin, bladder, kidney, etc.)
Section 16: 317. Never get sick
Section 16: 318. Acne (adult)
Section 16: 319. Itchy skin (Dermatitis)
Section 16: 320. Cysts, boils, rashes
Section 16: 321. History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition