Free Nutrition Health Survey!

General Information

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Sex: MaleFemale

Age

Patient's Health Professional

 

Street Address

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State

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Part I

Check any of the following medications you are taking:

AntacidsAntibiotic/AntifungalAntidepressantsAntidiabetic/InsulinAspirin/TylenolChemotherapyCortisone Anti-Inflammatories DiureticsHeart MedicationsHigh Blood PressureHormonesLaxativesLithiumOral Contraceptives RadiationRelaxants/Sleeping PillsRecreational DrugsThyroidUlcer Medications

Recreational Drugs (list):

Other (list):

Check if you eat, drink, or use:

AlcoholCandyCarbonated BeveragesCigarettesCoffeeDistilled Water Fluoridated/Chlorinated WaterAt fast food restaurants regularlyFried FoodsRefined (White) Flour ProductsLuncheon MeatsMargarine Refined SugarsMilk ProductsArtificial SweetenersNon-Herbal TeasChew TobaccoVitamins & Minerals

Vitamins & Minerals (list):

 


 

Part II - IMPORTANT

Please list your five major health concerns in order of importance:





 

Specify any drugs, vitamins and minerals not mentioned above:





 


 

Part III

DIRECTIONS: Please read each description and choose description that best describes the frequency of your symptoms within the past year.

Mild = Occurs once a month or less
Moderate = Occurs several times monthly
Severe = Aware of it almost constantly

Section A
Never
Mild
Moderate
Severe
A.01. History of constipation?
0123
A.02. Bad breath/halitosis?
0123
A.03. Loss of taste for meat?
0123
A.04. Belching shortly after meals?
0123
A.05. Bloating or gas shortly after meals?
0123
Section B
Never
Mild
Moderate
Severe
B.01. Burning or gnawing stomach pain?
0123
B.02. Heartburn or indigestion after meals?
0123
B.03. Stomach pain from stress and/or spicy foods?
0123
B.04. Told you have Ulcers?
0123
B.05. Use antacids or aspirin?
0123
B.06. Use milk or carbonated drinks to relieve stomach pain?
0123
Section C
Never
Mild
Moderate
Severe
C.01. Remnants of food or fibers in stools?
0123
C.02. Nausea or diarrhea?
0123
C.03. Mucus in stools?
0123
C.04. Pass gas frequently?
0123
Section D
Never
Mild
Moderate
Severe
D.01. Pain or discomfort in abdomen area?
0123
D.02. Have allergies?
0123
D.03. Self or Family history of autoimmune disease?
0123
D.04. Drink alcohol?
0123
D.05. Drink milk or eat dairy products?
0123
D.06. Often have constipation or diarrhea?
0123
D.07. Frequently have gas?
0123
Section E
Never
Mild
Moderate
Severe
E.01. Coated or fuzzy debris on tongue?
0123
E.02. Bowel movements painful or difficult?
0123
E.03. Irritable bowel or colitis?
0123
E.04. Have bad breath?
0123
Section F
Never
Mild
Moderate
Severe
F.01. Burning or itching anus?
0123
F.02. Frequently get skin eruptions or bumps?
0123
F.03. History of yeast infections, antibiotic use?
0123
F.04. Use or have used estrogen compounds?
0123
F.05. Have intestinal pain for no apparent reason?
0123
F.06. Have diarrhea?
0123
F.07. Have allergies or sensitivities?
0123
F.08. Get sick often or stay sick?
0123
F.09. Feel tired all the time?
0123
Section G
Never
Mild
Moderate
Severe
G.01. Pain or discomfort on right side under ribcage?
0123
G.02. Blurred vision?
0123
G.03. Intolerance to greasy foods?
0123
G.04. Eat fast food?
0123
G.05. Tightness or pain between shoulder blades?
0123
G.06. Light-colored or foul smelling stools?
0123
G.07. Feel nauseous or queasy after eating fatty foods?
0123
G.08. Drink coffee?
0123
G.09. Dry skin, itchy or peeling feet?
0123
G.10. Retaining water?
0123
G.11. Gag easily?
0123
G.12. Sour or metallic taste in mouth?
0123
Section H
Never
Mild
Moderate
Severe
H.01. Feet burn?
0123
H.02. Noises in head or ringing in the ears?
0123
H.03. Strong light irritates eyes?
0123
H.04. Drink alcohol?
0123
H.05. Sensitive to fumes, smoke, smells, or chemicals?
0123
H.06. Thick stringy mucus or swollen lymph nodes?
0123
H.07. Have allergies?
0123
H.08. Eat luncheon meat?
0123
H.09. Bronzing of skin or brown spots?
0123
Section I
Never
Mild
Moderate
Severe
I.01. Head congestion or sinus fullness?
0123
I.02. Frequent sneezing?
0123
I.03. Eyes and nose watery, swollen or puffy?
0123
I.04. Nightmare-like dreams?
0123
I.05. Dark circles under eyes?
0123
I.06. Certain foods cause distress (dairy, corn, wheat)?
0123
I.07. Sensitive to fumes, smoke or chemicals?
0123
I.08. Thick mucus or swollen lymph nodes?
0123
I.09. Chronic sinus infections?
0123
Section J
Never
Mild
Moderate
Severe
J.01. Crave sweets or coffee in afternoon or mid-morning?
0123
J.02. Hungry between meals or excessive appetite?
0123
J.03. Irritable before meals or if meals delayed?
0123
J.04. Get shaky or light-headed if meals delayed?
0123
J.05. Wake in the night and can't go back to sleep?
0123
J.06. Problems with memory in mid-morning or after noon?
0123
J.07. Eat sweets, refined foods, or fast foods?
0123
Section K
Never
Mild
Moderate
Severe
K.01. Family history of diabetes?
0123
K.02. Excessive thirst?
0123
K.03. Excessive urination?
0123
K.04. Fasting glucose greater than 120 mg/dl?
0123
K.05. Overweight by 50 or more pounds?
0123
Section L
Never
Mild
Moderate
Severe
L.01. Difficulty maintaining chiropractic adjustments?
0123
L.02. Crave salt?
0123
L.03. Low blood pressure?
0123
L.04. Weakness after colds or slow recovery?
0123
L.05. Headaches in afternoon?
0123
L.06. Muscular or nervous exhaustion?
0123
L.07. Chronic fatigue or slow starter in the morning?
0123
L.08. Have allergies or sensitivities?
0123
Section M
Never
Mild
Moderate
Severe
M.01. Have anxiety?
0123
M.02. Problems sleeping or insomnia?
0123
M.03. Crave sweets or coffee in the afternoon or mid-morning?
0123
M.04. Get shaky or light-headed if meals delayed?
0123
M.05. Retain water?
0123
M.06. Are under a lot of stress?
0123
M.07. Feel tired or sleepy in afternoon?
0123
M.08. Eat refined flour products, sugar or drink coffee?
0123
Section N
Never
Mild
Moderate
Severe
N.01. Hair and skin dry but not coarse?
0123
N.02. Weight gain around hips and waist?
0123
N.03. Sex drive reduced or absent?
0123
N.04. Impotence or decrease in size of testes (males).
0123
N.05. Infertile or decrease in size of breasts (females).
0123
N.06. Abnormal thirst?
0123
N.07. Lack of menstruation (females)?
0123
Section O
Never
Mild
Moderate
Severe
O.01. Feel worse after chiropractic adjustment?
0123
O.02. Forgetful, mental sluggishness, or reduced initiative?
0123
O.03. Skin coarse and dry?
0123
O.04. Cold hands and feet?
0123
O.05. Frequent constipation?
0123
O.06. Headaches upon awakening?
0123
O.07. Gain weight easily?
0123
O.08. Cry easily, worse with change in season?
0123
O.09. Hair thin or falling out?
0123
O.10. Feel depressed?
0123
Section P - Only Females Answer Section P
Never
Mild
Moderate
Severe
P.01. Menstruates too frequently?
0123
P.02. Acne worse at menses?
0123
P.03. Scanty or missed menses?
0123
P.04. Painful or tender breasts?
0123
P.05. Have had hysterectomy?
0123
P.06. Mood changes or irritability before menses?
0123
P.07. Painful menses or cramping during menses?
0123
P.08. Menstruation excessive or prolonged?
0123
P.09. Menopausal depression?
0123
P.10. Have hot flashes?
0123
P.11. Depression before menses?
0123
Section Q - Only Males Answer Section Q
Never
Mild
Moderate
Severe
Q.01. History of prostate problems?
0123
Q.02. Decreased size and force of urinary stream?
0123
Q.03. Reduced sex drive?
0123
Q.04. Dribbling after urination?
0123
Q.05. Frequent night urination?
0123
Q.06. Feeling of incomplete bowel evacuation?
0123
Q.07. Difficulty stopping urinary flow?
0123
Q.08. Leg nervousness at night?
0123
Q.09. Pain on side of legs or on inside of heels?
0123
Section R
Never
Mild
Moderate
Severe
R.01. Chest pain or shortness of breath on exertion?
0123
R.02. Swollen ankles, worse at night?
0123
R.03. Personal or family history or cardiovascular disease?
0123
R.04. High cholesterol or triglycerides?
0123
R.05. Pain under sternum that radiates to the left shoulder?
0123
R.06. Air hunger, sigh frequently or labored breathing?
0123
R.07. Irregular heartbeat?
0123
R.08. Snores while sleeping?
0123
R.09. Pain, cramp or tired feeling in foot, calf and hip?
0123
Section S
Never
Mild
Moderate
Severe
S.01. Have bronchial asthma or bronchitis?
0123
S.02. Frequent lung congestion?
0123
S.03. Live or work around people who smoke?
0123
S.04. Recurrent sinus or upper-respiratory infections?
0123
S.05. Chronic cough?
0123
Section T
Never
Mild
Moderate
Severe
T.01. Recurrent bladder or kidney infections?
0123
T.02. Painful burning when passing urine?
0123
T.03. Cloudy, rose-colored, or strong-smelling urine?
0123
T.04. Difficulty urinating?
0123
T.05. Urinary leakage or bedwetting?
0123
T.06. Back pain in kidney area?
0123
T.07. History of kidney problems?
0123
T.08. Have skin eruptions such as psoriasis or eczema?
0123
Section U
Never
Mild
Moderate
Severe
U.01. Pain in neck or shoulders?
0123
U.02. Tightness in shoulder muscles?
0123
U.03. Muscle cramps or spasms?
0123
U.04. Muscles and joints sore all over?
0123
Section V
Never
Mild
Moderate
Severe
V.01. Joint pain in hands or fingers?
0123
V.02. Told you have arthritis?
0123
V.03. Joint stiffness?
0123
V.04. Told you have herniated or slipped disc?
0123
Section W
Never
Mild
Moderate
Severe
W.01. Bones are sore or pain in fingers?
0123
W.02. Cavities or dentures?
0123
W.03. Gums bleed easily?
0123
W.04. Have muscle cramps?
0123
W.05. Told you have bone loss or Osteoporosis?
0123
Section X
Never
Mild
Moderate
Severe
X.01. Uncoordinated or unsteady walk?
0123
X.02. Pins and needle burning sensation in in hands or feet?
0123
X.03. Muscle weakness or reflex loss?
0123
X.04. Loss of sense of vibration in legs?
0123
X.05. Memory loss?
0123
X.06. Restless leg?
0123
X.07. Dizziness?
0123
X.08. Irritable or moody?
0123
Section Y
Never
Mild
Moderate
Severe
Y.01. Chronic infections?
0123
Y.02. Wounds heal slowly?
0123
Y.03. Loss of sense of taste and smell?
0123
Y.04. Fatigued?
0123
Y.05. White spots under fingernails?
0123
Section ZA
Never
Mild
Moderate
Severe
ZA.01. Night vision poor?
0123
ZA.02. Strong light irritates eyes?
0123
ZA.03. Noises in head or ringing in ears?
0123
Section ZB
Never
Mild
Moderate
Severe
ZB.01. Vulnerable to insect bites?
0123
ZB.02. Loss of muscle tone or heaviness in arms and legs?
0123
ZB.03. Worrier, feel insecure, or highly emotional?
0123
ZB.04. Slow pulse or irregular heartbeat?
0123
ZB.05. Poor appetite?
0123
Section ZC
Never
Mild
Moderate
Severe
ZC.01. Burning sensation in mouth?
0123
ZC.02. Cannot recall dreams?
0123
ZC.03. Numbness in hands and/or feet?
0123
ZC.04. Intolerance to MSG?
0123
Section ZD
Never
Mild
Moderate
Severe
ZD.01. Intolerance to sulfites (found in wine)?
0123
ZD.02. Sensitive to perfumes or smells?
0123
Section ZE
Never
Mild
Moderate
Severe
ZE.01. Frequently irritable?
0123
ZE.02. Easily startled or nervous?
0123
ZE.03. Muscle, leg, or toe cramping at rest?
0123
ZE.04. Body odor or foot odor?
0123
ZE.05. Crave chocolate?
0123
Section ZF
Never
Mild
Moderate
Severe
ZF.01. "Lump in throat?
0123
ZF.02. Dry mouth, eyes or nose?
0123
ZF.03. Gag easily?
0123
Section ZG
Never
Mild
Moderate
Severe
ZG.01. Fatigued all the time?
0123
ZG.02. Nails weak or ridged?
0123
ZG.03. History of anemia?
0123
ZG.04. Hands and feet often cold?
0123
ZG.05. Crave ice?
0123
ZG.06. "Whites of eyes are blue tinted?
0123
Section ZH
Never
Mild
Moderate
Severe
ZH.01. Gums bleed easily?
0123
ZH.02. Bruise easily?
0123
Section ZI
Never
Mild
Moderate
Severe
ZI.01. Poor wound healing?
0123
ZI.02. Dry skin?
0123
ZI.03. Vision blurred or impaired?
0123
ZI.04. Chronic infections?
0123
ZI.05. Frequent skin problems?
0123