Nutritional Assessment Questionnaire -2020

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