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DCNutrition Health Survey

July 30, 2010

Name:
Email Address:
Mail Address:
	City: State: Zipcode:
Sex:	Male Female
Age:
Patient's Health Professional:

Part I

Check any of the following medications you are taking:

Antacids
Antibiotic/Antifungal
Antidepressants
Antidiabetic/Insulin
Aspirin/Tylenol
Chemotherapy
Cortisone Anti-Inflammatories
   Diuretics
Heart Medications
High Blood Pressure
Hormones
Laxatives
Lithium
Oral Contraceptives
   Radiation
Relaxants/Sleeping Pills
Recreational Drugs
        Specify:
Thyroid
Ulcer Medications
Other
        Specify:

Check if you eat, drink, or use:

Alcohol
Candy
Carbonated Beverages
Cigarettes
Coffee
Distilled Water
   Fluoridated/Chlorinated Water
At fast food restaurants regularly
Fried Foods
Refined (White) Flour Products
Luncheon Meats
Margarine
   Refined Sugars
Milk Products
Artificial Sweeteners
Non-Herbal Teas
Chew Tobacco
Vitamins & Minerals
        Specify:

Part II - IMPORTANT

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

1.

2.

3.

4.

5.

Specify any drugs, vitamins and minerals not mentioned
above:

1.

2.

3.

4.

5.

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

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