FibromyalgiaHope.com s Nutritional Assessment
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1 FibromyalgiaHope.com s Nutritional Assessment Print the Assessment. Check any symptoms that apply to you. The more checks under a category, the more you may benefit from the nutrient or supplement that corresponds to that Category. In no way should this form be mistaken as a diagnosis of a disease, nor should supplements be expected to cure any disease. Directions for returning the results to Anita, so that you may receive your Personalized Supplement Program, are at the end. Full Name Address Category 1 tired all the time irritability crave sweets/caffeine headaches stress PMS rapid heartbeat/palpitations anxiety ridges in nails skin problems/hair loss pregnancy/morning sickness carpal tunnel syndrome women of childbearing age cracks at corner of mouth premature gray hair Category 2 catch colds often chronic infections bruise easily/slow healing varicose veins/spider veins allergies, frequent colds arthritis back/neck pain smoke cigarettes stress cancer prevention macular degeneration weakened teeth/enamel take oral contraceptives bleeding gums iron deficiency heavy metals/toxins Category 3 asthma poor circulation high blood pressure diabetes slow to heal PMS autoimmune disorders menopause/hot flashes restless leg syndrome cold hands and/or feet varicose veins Category 4 go to bed tired/wake up tired weakness/weak muscles dry, lifeless hair splitting nails difficulty concentrating hormonal imbalances osteoporosis/low bone density low/fluctuating blood sugar menopausal symptoms thyroid problems poor digestion slow healing premature aging low immunity
2 Category 5 muscle cramps/tension irritability insomnia/sleep problems tooth decay/cavities/grinding PMS/menstrual cramps fibromyalgia joint pains weak fingernails osteoporosis or family history of back aches irregular heartbeat/palpitations headaches/migraines colon cancer history low dairy intake Category 6 constipation or history of toxicity low nutrient absorption history of food allergies Category 7 allergies/asthma arthritis/joint pain/gout sinus infections low fiber diet/constipation digestive problems kidney/bladder infections bad breath/body odor excess fluid retention Category 8 frequent antibiotic/med. Use repeat ear/throat infections Crohn s/colitis/ibs sensitivity to odors/scents rashes/eczema/psoriasis recurrent sinus infections allergies/food sensitivities vaginal/bladder infections candida white coating on tongue Category 9 liver damage hepatitis, cirrhosis take OTC/prescription meds blurred/tunnel vision food allergies/intolerances dark circles/bags under eyes canker sores/acne candida/yeast overgrowth eczema/psoriasis/hives low hormone production Category 10 repeated colds, infections, flu asthma allergies cancer prevention immune system problems Category 11 using cholesterol lowering meds fatigue, lack of energy cold hands/feet irregular heart beat fluid retention/edema Alzheimer s poor circulation Category 12 not enough hours in the day! feeling stressed out often! time-pressure deadlines muscle tension angry outbursts difficulty concentrating Category 13 I burn the candle at both ends recurrent fatigue mental/physical exhaustion no initiative low blood pressure high levels of stress blood sugar irregularities poor appetite
3 Category 14 high blood sugar type II diabetes crave sweets, bread, pasta high triglycerides low HDL cholesterol more than 2 serv. caffeine/day Category 15 osteoarthritis sports injuries decreased mobility cartilage degeneration Category 16 repetitive stress on joints arthritis pain my joints suffer from overuse Category 17 arthritis pain muscle strains neck/shoulder pain backaches sore joints I am a weekend warrior Category 18 food intolerances (lactose) gas/bloating/rumbling stomach indigestion lack of raw foods in diet Category 19 trouble concentrating ADD/ADHD poor memory dementia/alzheimer s vertigo/dizzy/ringing in ears macular degeneration headaches diabetic circulation problems cataracts, glaucoma Category 20 PMS/menstrual regularities skin eruptions/dryness/eczema fibrocystic disorders arthritic pain and swelling multiple sclerosis dry eye syndrome fertility problems menopausal symptoms Category 21 hot flashes sleep disturbances anxiety/jumpiness short-tempered /weepiness heart pounding while resting Category 22 melancholy loss of interest in life lack of initiative sleep disorders emotional distress/stress Category 23 slow thinking brain fog difficult to remember things trouble focusing slow reaction time high stress aluminum, lead toxicity vertigo
4 Category 24 viral/bacterial infections weak immune system frequent sore throat quick fix at first sign of cold/flu Category 25 acid indigestion/gas/bloating morning sickness motion sickness Category 26 insomnia TMJ/muscle tension headaches/anxiety rapid heartbeat hyperactivity Category 27 blood clots, aneurysms viral, bacterial infections yeast infections/candida sinus infections allergies/asthma colitis weakened immune system Category 28 anemia heavy menstruation dark circles under eyes vegetarian diet low energy/fatigue/stress Category 29 poor memory concentration problems learning challenges nerve damage/ms trying to lose weight Category 30 poor circulation/blood clots migraine headaches learning challenges, ADD autism, development disorders eczema, psoriasis ulcerative colitis lupus/multiple sclerosis bipolar disorder asthma, allergies Category 31 constipation acne body odor diabetes frequent headaches/migraines colon problems diet high in processed foods Category 32 asthma/allergies skin issues respiratory infections bronchitis/pneumonia viruses/weak immune system family cancer history exposure to toxins < 5 servings/day fruits/veggies Category 33 < 5 servings/day fruits/veggies liver toxins/problems intestinal toxins/problems
5 Instructions for Returning the Results of your Nutritional Assessment to Anita: Your Best Choice is to fax the 4 pages of the Assessment to me at Be sure to include your name and address, and send me an when you fax it, so we make sure it reaches me. Please do not send anything to me as an attachment I do not open attachments. Option Number 2 is to Record the number of checks you had in each Category in the List below. Then, open a new addressed to me: anitamurray@earthlink.net Enter the number of checks for each category directly into this . For instance, Cat.1=4, Cat.2=7, Cat.3=0, Cat.4=9, etc. Double check your results, please. to me. Category List Category 1: Category 2: Category 3: Category 4: Category 5: Category 6: Category 7: Category 8: Category 9: Category 10: Category 11: Category 12: Category 13: Category 14: Category 15: Category 16: Category 17: Category 18: Category 19: Category 20: Category 21: Category 22: Category 23: Category 24: Category 25: Category 26: Category 27: Category 28: Category 29: Category 30: Category 31: Category 32: Category 33:
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Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex
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Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
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Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA Patient Intake Form
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IS YOUR GUT LEAKY? ASSESSMENT JJ VIRGIN
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Nutrition Questionnaire
Nutrition Questionnaire This office deals with the health, vitality and longevity of the individual. The following questions will help us to more accurately design a personalized program to allow you to
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We