NAQ. 0: Never Consume 1: Consume 1-2x/month 2: Consume Weekly 3: Consume Daily
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1 Name: Gender: Date: Date of Birth: TOP 5 HEALTH CONCERNS 1: 2: 3: 4: 5: Directions: Please read the following questions and circle the number that applies. Unless otherwise noted, use the default scale shown at the top of each section or page. Trust your instincts and choose quickly without overthinking. Part 1 DIET Section Subtotal / 58 0: Never Consume 1: Consume 1-2x/month 2: Consume Weekly 3: Consume Daily Alcohol Artificial Sweeteners Candy, Desserts, Sugar Carbonated Beverages Chewing Tobacco Cigarettes Cigars or Pipes Caffeinated Beverages Fast Food Fried Foods Processed Lunch Meats Margarine Milk Products Radiation Exposure (0=No, 1=Yes) Refined Flour & Baked Goods Vitamins & Minerals Distilled Water Tap Water Well Water Restrict Calories for Weight Control LIFESTYLE Section Subtotal / 12 See each question below for the rating key Exercise Sessions Per Week 0 = 2+ times/week; 1 = 1 time/week; 2 = 1-2 times/week; 3 = < 1 time/month Changed Jobs 0 = over 12 mo. ago; 1 = last 12 mo.; 2 = last 6 mo.; 3 = last 2 mo Divorced 0 = never or over 2 years ago; 1 = last 2 years.; 2 = last year; 3 = last 6 mo Work 60+ Hours Per Week 0 = never; 1 = occasionally; 2 = usually; 3 = always Nutritional Therapy Association, Inc. 1
2 MEDICATIONS Section Subtotal / 54 0: No (Not Taking or Have Not Taken in the Last Month) 1: Yes (Currently Taking or Have Taken in the Last Month) Antacids Antianxiety Medications Antibiotics Anticonvulsants Antidepressants Antifungals Aspirin/Ibuprofen Asthma Inhalers Beta Blockers Birth Control Pill/Implant Chemotherapy Cholesterol Lowering Medications Cortisone/Steroids Diuretics Estrogen or Progesterone (Prescript.) Estrogen or Progesterone (Natural) Heat Medications High Blood Pressure Medications Laxatives Recreational Drugs Relaxants/Sleeping Pills Testosterone (Prescript. or Natural) Thyroid Medication Acetaminophen (Tylenol ) Ulcer Medications Sildenafil Citrate (Viagra ) Diabetic Medications/Insulin Part 2 SECTION 1 Section Subtotal / Belching/Gas Within 1 Hour of Eating Heartburn or Acid Reflux Bloating Within 1 Hour of Eating Vegan Diet ¹ Bad Breath (Halitosis) Loss of Taste for Meat Strong Smelling Sweat Stomach Upset by Taking Vitamins Sense of Excess Fullness After Meals Feel Like Skipping Breakfast Feel Better if You Don t Eat Sleepy After Meals Fingernails Chip, Peal or Break Easily Anemia Unresponsive to Iron Stomach Pains or Cramps Chronic Diarrhea Diarrhea Shortly After Meals Black or Tarry Colored Stools Undigested Food in Stool ¹ 0 = No 1 = Yes No animal products (meat, fish, eggs, dairy, etc.) Nutritional Therapy Association, Inc. 2
3 SECTION 2 Section Subtotal / Pain Between Shoulder Blades Stomach Upset by Greasy Foods Greasy or Shiny Stools Nausea ¹ Motion Sickness (Sea, Car, Airplane) History of Morning Sickness ¹ Light or Clay Colored Stools Dry Skin, Itchy or Peeling Feet Headache Over Eyes Gallbladder Attacks ² Gallbladder Removed ¹ Bitter Taste in Mouth, Especially After Meals Become Sick When Drinking Wine ¹ Easily Intoxicated from Wine ¹ Easily Hungover from Wine ¹ Alcoholic Beverages Per Week ³ Recovering Alcoholic ¹ History of Drug Abuse ¹ History of Hepatitis ¹ Long-term Use of Prescript./Rec. Drugs ¹ Sensitive to Chemicals (e.g. Perfume, Cleaning Agents, etc.) Sensitive to Tobacco Smoke Exposure to Diesel Fumes Pain Under Right Side of Rib Cage Hemorrhoids or Varicose Veins Consume NutraSweet (Aspartame) Sensitive to Aspartame Chronic Fatigue or Fibromyalgia ¹ 0 = No 1 = Yes ² 0 = Never 1 = Years Ago 2 = Within Last Year 3 = Within Past 3 Months ³ 0 = < 3 1 = < 7 2 = < 14 3 = > 14 SECTION 3 Section Subtotal / Food Allergies Abdominal Bloating 1-2 Hours After Meal Specific Foods Make You Tired / Bloated ¹ Pulse Speeds After Eating Airborne Allergies Experience Hives Sinus Congestion, Stuffy Head Crave Bread or Noodles Crohn s Disease ² Wheat or Grain Sensitivity Dairy Sensitivity Are There Any Foods You Can t Give Up? ¹ Asthma, Sinus Infections, Stuffy Nose Bizarre, Vivid Dreams; Nightmares Use Over-the-Counter Pain Meds Feel Spacey or Unreal Alternating Constipation/Diarrhea ¹ 0 = No 1 = Yes ² 0 = No 1 = Yes in the Past 2 = Currently Mild 3 = Currently Severe Nutritional Therapy Association, Inc. 3
4 SECTION 4 Section Subtotal / Anus Itches Coated Tongue Feel Worse in Moldy/Musty Places Total Antibiotic Use ² Fungal or Yeast Infections Ring Worm, Jock Itch, Athletes Foot, Nail Fungus Yeast Symptoms Increase with Sugar, Starch, or Alcohol Consumption Hard or Difficult to Pass Stool History of Parasites ¹ Less Than 1 Bowel Movement/Day Stools Have Corners/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 Flatulence Bad Breath or Strong Body Odors Painful to Press Along Outer Thighs (Iliotibial Bands) Cramps in Lower Abdominal Region Dark Circles Under Eyes ¹ 0 = No 1 = Yes ² 0 = Never 1 = Less than 1 Month 2 = Less than 3 Months 3 = More than 3 Months SECTION 5 Section Subtotal / History of Carpal Tunnel Syndrome ¹ History of Lower Right Abdominal Pains or Ileocecal Valve Problems ¹ History of Stress Fracture ¹ Bone Loss (Reduced Density on Bone Scan) Are You Shorter Than You Used to Be? ¹ Calf, Foot, or Toe Cramps at Rest Frequent Fevers Cold Sores, Fever Blisters, or Herpes Lesions Frequent Skin Rashes or Hives Herniated Disc ¹ Excessively Flexible Joints / Double Jointed Joints Pop or Click Pain or Swelling in Joints Bursitis or Tendonitis History of Bone Spurs ¹ Morning Stiffness Nausea with Vomiting Crave Chocolate Feet Have a Strong Odor History of Anemia Whites of Eyes (Sclera) are Blue Tinted Hoarseness Difficulty Swallowing Lump in Throat Dry Mouth, Eyes, or Nose Gag Easily White Spots on Fingernails Cuts Heal Slowly and/or Scar Easily Decreased Sense of Taste or Smell ¹ 0 = No 1 = Yes Nutritional Therapy Association, Inc. 4
5 SECTION 6 Section Subtotal / Experience Pain Relief with Aspirin ¹ Crave Fatty or Greasy Foods Low-Fat or Reduced-Fat Diet ² Tension Headaches at Base of Skull Headaches When Out in the Hot Sun Sunburn Easily or Get Sun Poisoning Muscles Easily Fatigued Dry, Flaky Skin or Dandruff ¹ 0 = No 1 = Yes ² 0 = Never 1 = Years Ago 2 = Within Past Year 3 = Currently SECTION 7 Section Subtotal / Crave Sweets Awaken a Few Hours After Falling Asleep & Have Difficulty Falling Back to Sleep Binging or Uncontrolled Eating Excessive Appetite Crave Coffee or Sugar in the Afternoon Sleep in the Afternoon Fatigue that is Relieved by Eating Headache if Meals are Skipped / Delayed Irritable Before Meals Shaky if Meals are Delayed Family Members with Diabetes ¹ Frequent Thirst Frequent Urination ¹ 0 = None 1 = 1-2 People 2 = 3-4 People 3 = > 4 People SECTION 8 Section Subtotal / 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 Beats Per Minute ¹ Ringing in the Ears (Tinnitus) Depressed Numbness, Tingling, or Itching in Hands & Feet Fear of Impending Doom Worrier, Apprehensive, Anxious Nervous or Agitated Feelings of Insecurity Heart Races Can Hear Heartbeat on Pillow at Night Whole Body or Limb Jerk as Falling Asleep Night Sweats Restless Leg Syndrome Cracks at Corner of Mouth (Cheilosis) Polyps or Warts MSG Sensitivity Fragile, Easily Chaffed Skin (e.g. When Shaving) Wake Up Without Remembering Dreams Small Bumps on Back of Arms Strong Light at Night Irritates Eyes Nose Bleeds and/or Tends to Bruise Easily Bleeding Gums, Especially When Brushing ¹ 0 = No 1 = Yes Nutritional Therapy Association, Inc. 5
6 SECTION 9 Section Subtotal / 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/ Headache After Exercising Feeling Wired or Jittery After Drinking Coffee Clench or Grind Teeth Calm on the Outside, Troubled on the Inside Chronic Lower Back Pain, Worse with Fatigue Become Dizzy When Standing Up Quickly Difficulty Maintaining Manipulative Correction Pain After Manipulative Correction 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 Knee Tendency to Sprain Ankles or Get Shin Splints Tendency to Need Sunglasses Allergies and/or Hives Weakness, Dizziness SECTION 10 Section Subtotal / Height Over 6 6 ¹ Early Sexual Development ¹ (Before Age 10) Increased Libido Splitting Type Headache Memory Failing Tolerate / Feel Fine When Eating Sugar ¹ Height Under 4 10 ¹ Decreased Libido Excessive Thirst Weight Gain Around Hips or Waist Menstrual Disorders Delayed Sexual Development ¹ (After Age 13) Tendency to Ulcers or Colitis ¹ 0 = No 1 = Yes Nutritional Therapy Association, Inc. 6
7 SECTION 11 Section Subtotal / Sensitive/Allergic to Iodine Difficulty Gaining Weight (Even With Large Appetite) Nervous or Emotional (Can t Work Under Pressure) Inward Trembling Flush Easily Fast Pulse at Rest Intolerance to High Temperatures Difficulty Losing Weight Mentally Sluggish / Reduced Initiative Easily Fatigued / Sleepy During the Day Sensitive to Cold / Poor Circulation (Cold Hands & Feet) Chronic Constipation Excessive Hair Loss and/or Course Hair Morning Headaches (Wear Off During the Day) Loss of Lateral (Outside) ⅓ of Eyebrow Seasonal Sadness SECTION 12: MEN ONLY Section Subtotal / Prostate Problems Difficulty with Urination / Dribbling Difficult to Start & Stop Urine Stream Pain or Burning During Urination 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* * Dysfunction related to prostate issues only. SECTION 13: WOMEN ONLY Section Subtotal / 60 If you are in menopause or no longer menstruating, please indicate the average symptoms that occurred when you were last menstruating Depression During Periods Mood Swings Associated with Periods (Premenstrual Syndrome) 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 Breast Fibroids / Benign Masses Painful Intercourse (Dyspareunia) Vaginal Discharge Vaginal Dryness Vaginal Itchiness Gain Weight Around Hips, Thighs & Buttocks Excess Facial or Body Hair Hot Flashes Night Sweats (in Menopausal Women) Thinning Skin Nutritional Therapy Association, Inc. 7
8 SECTION 14 Section Subtotal / Aware of Heavy 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 Ankles Swell, Especially at End of Day Cough at Night Blush / Face Turns Red for No Reason Dull Pain or Tightness in Chest and/or Radiating Into Right Arm (Worse with Exertion) Muscle Cramps with Exertion SECTION 15 Section Subtotal / Pain in Mid-Back Region Puffy / Dark Circles Around the Eyes History of Kidney Stones ¹ Cloudy, Bloody, or Darkened Urine Urine Has a Strong Odor ¹ 0 = No 1 = Yes SECTION 16 Section Subtotal / Runny or Drippy Nose Catch Colds at the Beginning of Winter Mucus Producing Cough Frequent Colds of Flu¹ Other Infections¹ (e.g. Sinus, Ear, Lung, Skin, Bladder, Kidney, etc.) Never Get Sick² Adult Acne Itchy Skin (Dermatitis) Cysts, Boils, or Rashes History of Chronic Viral Condition³ (e.g. Mono, Epstein Bar, Herpes, Shingles, Chronic Fatigue Syndrome) ¹ 0 = 1 or Less Per Year 1 = 2 to 3 per Year 2 = 4 to 5 Per Year 3 = 6 or More Per Year ² 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 ³ 0 = No 1 = Yes in the Past 2 = Currently Mild Condition 3 = Severe Nutritional Therapy Association, Inc. 8
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