"Nutritional Assessment Questionnaire Form - Nutritional Therapy Association"

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Nutritional Assessment Questionnaire 1.5
Name: _________________________________________________________
Date: _____/____/_____
Birth Date: __________________________
Gender: ______________
Please list your five major health concerns in order of importance:
1.
Notes:
2.
3.
4.
5.
PART I
Read the following questions and circle the number that applies:
KEY:
0 = Do not consume or use
2 = Consume or use weekly
1 = Consume or use 2 to 3 times monthly
3 = Consume or use daily
DIET
58
1.
Alcohol
7.
Cigars/pipes
14.
Radiation exposure (0=no, 1=yes)
0 1 2 3
0 1 2 3
0 1
2.
Artificial sweeteners
8.
Caffeinated beverages
15.
Refined flour/baked goods
0 1 2 3
0 1 2 3
0 1 2 3
3.
Candy, desserts, refined
9.
Fast foods
16.
Vitamins and minerals
0 1 2 3
0 1 2 3
0 1 2 3
sugar
10.
Fried foods
17.
Water, distilled
0 1 2 3
0 1 2 3
4.
Carbonated beverages
11.
Luncheon meats
18.
Water, tap
0 1 2 3
0 1 2 3
0 1 2 3
5.
Chewing tobacco
12.
Margarine
19.
Water, well
0 1 2 3
0 1 2 3
0 1 2 3
6.
Cigarettes
13.
Milk products
20.
Diet often for weight control
0 1 2 3
0 1 2 3
0 1 2 3
LIFESTYLE
12
21.
Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a
0 1 2 3
month)
22.
Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
0 1 2 3
23.
Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
0 1 2 3
24.
Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
0 1 2 3
MEDICATIONS
Indicate any medications you’re currently taking or have taken in the last month (0=no, 1=yes):
54
25.
Antacids
39.
Diuretics
0 1
0 1
26.
Antianxiety medications
40.
Estrogen or progesterone (pharmaceutical,
0 1
0 1
27.
Antibiotics
prescription)
0 1
28.
Anticonvulsants
41.
Estrogen or progesterone (natural)
0 1
0 1
29.
Antidepressants
42.
Heart medications
0 1
0 1
30.
Antifungals
43.
High blood pressure medications
0 1
0 1
31.
Aspirin/Ibuprofen
44.
Laxatives
0 1
0 1
32.
Asthma inhalers
45.
Recreational drugs
0 1
0 1
33.
Beta blockers
46.
Relaxants/Sleeping pills
0 1
0 1
34.
Birth control pills/implant contraceptives
47.
Testosterone (natural or prescription)
0 1
0 1
35.
Chemotherapy
48.
Thyroid medication
0 1
0 1
36.
Cholesterol lowering medications
49.
Acetaminophen (Tylenol)
0 1
0 1
37.
Cortisone/steroids
50.
Ulcer medications
0 1
0 1
38.
Diabetic medications/insulin
51.
Sildenafal citrate (Viagra)
0 1
0 1
PART II
(See key at bottom of page)
Section 1
55
52.
Belching or gas within one hour after eating
61.
Feel like skipping breakfast
0 1 2 3
0 1 2 3
53.
Heartburn or acid reflux
62.
Feel better if you don’t eat
0 1 2 3
0 1 2 3
54.
Bloating within one hour after eating
63.
Sleepy after meals
0 1 2 3
0 1 2 3
55.
Vegan diet (no dairy, meat, fish or eggs) (0=no,
64.
Fingernails chip, peel or break easily
0 1
0 1 2 3
1=yes)
65.
Anemia unresponsive to iron
0 1 2 3
56.
Bad breath (halitosis)
66.
Stomach pains or cramps
0 1 2 3
0 1 2 3
57.
Loss of taste for meat
67.
Diarrhea, chronic
0 1 2 3
0 1 2 3
58.
Sweat has a strong odor
68.
Diarrhea shortly after meals
0 1 2 3
0 1 2 3
59.
Stomach upset by taking vitamins
69.
Black or tarry colored stools
0 1 2 3
0 1 2 3
60.
Sense of excess fullness after meals
70.
Undigested food in stool
0 1 2 3
0 1 2 3
KEY: 0=No, symptom does not occur
2=Moderate symptom, occurs occasionally (weekly)
1=Yes, minor or mild symptom, rarely occurs (monthly)
3=Severe symptom, occurs frequently (daily)
®
©2003 Nutritional Therapy Association, Inc.
All Rights Reserved.
Nutritional Assessment Questionnaire 1.5
Name: _________________________________________________________
Date: _____/____/_____
Birth Date: __________________________
Gender: ______________
Please list your five major health concerns in order of importance:
1.
Notes:
2.
3.
4.
5.
PART I
Read the following questions and circle the number that applies:
KEY:
0 = Do not consume or use
2 = Consume or use weekly
1 = Consume or use 2 to 3 times monthly
3 = Consume or use daily
DIET
58
1.
Alcohol
7.
Cigars/pipes
14.
Radiation exposure (0=no, 1=yes)
0 1 2 3
0 1 2 3
0 1
2.
Artificial sweeteners
8.
Caffeinated beverages
15.
Refined flour/baked goods
0 1 2 3
0 1 2 3
0 1 2 3
3.
Candy, desserts, refined
9.
Fast foods
16.
Vitamins and minerals
0 1 2 3
0 1 2 3
0 1 2 3
sugar
10.
Fried foods
17.
Water, distilled
0 1 2 3
0 1 2 3
4.
Carbonated beverages
11.
Luncheon meats
18.
Water, tap
0 1 2 3
0 1 2 3
0 1 2 3
5.
Chewing tobacco
12.
Margarine
19.
Water, well
0 1 2 3
0 1 2 3
0 1 2 3
6.
Cigarettes
13.
Milk products
20.
Diet often for weight control
0 1 2 3
0 1 2 3
0 1 2 3
LIFESTYLE
12
21.
Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a
0 1 2 3
month)
22.
Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
0 1 2 3
23.
Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
0 1 2 3
24.
Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
0 1 2 3
MEDICATIONS
Indicate any medications you’re currently taking or have taken in the last month (0=no, 1=yes):
54
25.
Antacids
39.
Diuretics
0 1
0 1
26.
Antianxiety medications
40.
Estrogen or progesterone (pharmaceutical,
0 1
0 1
27.
Antibiotics
prescription)
0 1
28.
Anticonvulsants
41.
Estrogen or progesterone (natural)
0 1
0 1
29.
Antidepressants
42.
Heart medications
0 1
0 1
30.
Antifungals
43.
High blood pressure medications
0 1
0 1
31.
Aspirin/Ibuprofen
44.
Laxatives
0 1
0 1
32.
Asthma inhalers
45.
Recreational drugs
0 1
0 1
33.
Beta blockers
46.
Relaxants/Sleeping pills
0 1
0 1
34.
Birth control pills/implant contraceptives
47.
Testosterone (natural or prescription)
0 1
0 1
35.
Chemotherapy
48.
Thyroid medication
0 1
0 1
36.
Cholesterol lowering medications
49.
Acetaminophen (Tylenol)
0 1
0 1
37.
Cortisone/steroids
50.
Ulcer medications
0 1
0 1
38.
Diabetic medications/insulin
51.
Sildenafal citrate (Viagra)
0 1
0 1
PART II
(See key at bottom of page)
Section 1
55
52.
Belching or gas within one hour after eating
61.
Feel like skipping breakfast
0 1 2 3
0 1 2 3
53.
Heartburn or acid reflux
62.
Feel better if you don’t eat
0 1 2 3
0 1 2 3
54.
Bloating within one hour after eating
63.
Sleepy after meals
0 1 2 3
0 1 2 3
55.
Vegan diet (no dairy, meat, fish or eggs) (0=no,
64.
Fingernails chip, peel or break easily
0 1
0 1 2 3
1=yes)
65.
Anemia unresponsive to iron
0 1 2 3
56.
Bad breath (halitosis)
66.
Stomach pains or cramps
0 1 2 3
0 1 2 3
57.
Loss of taste for meat
67.
Diarrhea, chronic
0 1 2 3
0 1 2 3
58.
Sweat has a strong odor
68.
Diarrhea shortly after meals
0 1 2 3
0 1 2 3
59.
Stomach upset by taking vitamins
69.
Black or tarry colored stools
0 1 2 3
0 1 2 3
60.
Sense of excess fullness after meals
70.
Undigested food in stool
0 1 2 3
0 1 2 3
KEY: 0=No, symptom does not occur
2=Moderate symptom, occurs occasionally (weekly)
1=Yes, minor or mild symptom, rarely occurs (monthly)
3=Severe symptom, occurs frequently (daily)
®
©2003 Nutritional Therapy Association, Inc.
All Rights Reserved.
Nutritional Assessment Questionnaire 1.5
Page 2 of 4
Section 2
68
71.
Pain between shoulder blades
85.
Easily hung over if you were to drink wine (0=no,
0 1 2 3
0 1
72.
Stomach upset by greasy foods
1=yes)
0 1 2 3
73.
Greasy or shiny stools
86.
Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14)
0 1 2 3
0 1 2 3
74.
Nausea
87.
Recovering alcoholic (0=no, 1=yes)
0 1 2 3
0 1
75.
Sea, car, airplane or motion sickness
88.
History of drug or alcohol abuse (0=no, 1=yes)
0 1 2 3
0 1
76.
History of morning sickness (0 = no, 1 = yes)
89.
History of hepatitis (0=no, 1=yes)
0 1
0 1
77.
Light or clay colored stools
90.
Long term use of prescription/recreational drugs
0 1 2 3
0 1
78.
Dry skin, itchy feet or skin peels on feet
(0=no, 1=yes)
0 1 2 3
79.
Headache over eyes
91.
Sensitive to chemicals (perfume, cleaning
0 1 2 3
0 1 2 3
80.
Gallbladder attacks (0=never, 1=years ago,
agents, etc.)
0 1 2 3
2=within last year, 3=within past 3 months)
92.
Sensitive to tobacco smoke
0 1 2 3
81.
Gallbladder removed (0=no, 1=yes)
93.
Exposure to diesel fumes
0 1
0 1 2 3
82.
Bitter taste in mouth, especially after meals
94.
Pain under right side of rib cage
0 1 2 3
0 1 2 3
83.
Become sick if you were to drink wine (0=no,
95.
Hemorrhoids or varicose veins
0 1
0 1 2 3
1=yes)
96.
Nutrasweet (aspartame) consumption
0 1 2 3
84.
Easily intoxicated if you were to drink wine
97.
Sensitive to Nutrasweet (aspartame)
0 1
0 1 2 3
(0=no, 1=yes)
98.
Chronic fatigue or Fibromyalgia
0 1 2 3
Section 3
47
99.
Food allergies
108.
Crohn's disease (0 =no, 1=yes in the past,
0 1 2 3
0 1 2 3
100.
Abdominal bloating 1 to 2 hours after eating
2=currently mild condition, 3=severe)
0 1 2 3
101.
Specific foods make you tired or bloated (0=no,
109.
Wheat or grain sensitivity
0 1
0 1 2 3
1=yes)
110.
Dairy sensitivity
0 1 2 3
102.
Pulse speeds after eating
111.
Are there foods you could not give up (0=no,
0 1 2 3
0 1
103.
Airborne allergies
1=yes)
0 1 2 3
104.
Experience hives
112.
Asthma, sinus infections, stuffy nose
0 1 2 3
0 1 2 3
105.
Sinus congestion, "stuffy head"
113.
Bizarre vivid dreams, nightmares
0 1 2 3
0 1 2 3
106.
Crave bread or noodles
114.
Use over-the-counter pain medications
0 1 2 3
0 1 2 3
107.
Alternating constipation and diarrhea
115.
Feel spacey or unreal
0 1 2 3
0 1 2 3
Section 4
58
116.
Anus itches
126.
Stools have corners or edges, are flat or ribbon
0 1 2 3
0 1 2 3
117.
Coated tongue
shaped
0 1 2 3
118.
Feel worse in moldy or musty place
127.
Stools are not well formed (loose)
0 1 2 3
0 1 2 3
119.
Taken antibiotic for a total accumulated time of
128.
Irritable bowel or mucus colitis
0 1 2 3
0 1 2 3
(0=never, 1= <1 month, 2= <3 months, 3= >3
129.
Blood in stool
0 1 2 3
months)
130.
Mucus in stool
0 1 2 3
120.
Fungus or yeast infections
131.
Excessive foul smelling lower bowel gas
0 1 2 3
0 1 2 3
121.
Ring worm, "jock itch", "athletes foot", nail fungus
132.
Bad breath or strong body odors
0 1 2 3
0 1 2 3
122.
Yeast symptoms increase with sugar, starch or
133.
Painful to press along outer sides of thighs
0 1 2 3
0 1 2 3
alcohol
(Iliotibial Band)
123.
Stools hard or difficult to pass
134.
Cramping in lower abdominal region
0 1 2 3
0 1 2 3
124.
History of parasites (0=no, 1=yes)
135.
Dark circles under eyes
0 1
0 1 2 3
125.
Less than one bowel movement per day
0 1 2 3
Section 5
75
136.
History of carpal tunnel syndrome (0=no, 1=yes)
150.
History of bone spurs (0=no, 1=yes)
0 1
0 1
137.
History of lower right abdominal pains or
151.
Morning stiffness
0 1
0 1 2 3
ileocecal valve problems (0=no, 1=yes)
152.
Nausea with vomiting
0 1 2 3
138.
History of stress fracture (0=no, 1=yes)
153.
Crave chocolate
0 1
0 1 2 3
139.
Bone loss (reduced density on bone scan)
154.
Feet have a strong odor
0 1 2 3
0 1 2 3
140.
Are you shorter than you used to be? (0=no,
155.
History of anemia
0 1
0 1 2 3
1=yes)
156.
Whites of eyes (sclera) blue tinted
0 1 2 3
141.
Calf, foot or toe cramps at rest
157.
Hoarseness
0 1 2 3
0 1 2 3
142.
Cold sores, fever blisters or herpes lesions
158.
Difficulty swallowing
0 1 2 3
0 1 2 3
143.
Frequent fevers
159.
Lump in throat
0 1 2 3
0 1 2 3
144.
Frequent skin rashes and/or hives
160.
Dry mouth, eyes and/or nose
0 1 2 3
0 1 2 3
145.
Herniated disc (0=no, 1=yes)
161.
Gag easily
0 1
0 1 2 3
146.
Excessively flexible joints, "double jointed"
162.
White spots on fingernails
0 1 2 3
0 1 2 3
147.
Joints pop or click
163.
Cuts heal slowly and/or scar easily
0 1 2 3
0 1 2 3
148.
Pain or swelling in joints
164.
Decreased sense of taste or smell
0 1 2 3
0 1 2 3
149.
Bursitis or tendonitis
0 1 2 3
KEY: 0=No, symptom does not occur
2=Moderate symptom, occurs occasionally (weekly)
1=Yes, minor or mild symptom, rarely occurs (monthly)
3=Severe symptom, occurs frequently (daily)
®
©2003 Nutritional Therapy Association, Inc.
All Rights Reserved.
Nutritional Assessment Questionnaire 1.5
Page 3 of 4
Section 6
22
165.
Experience pain relief with aspirin (0=no, 1=yes)
169.
Headaches when out in the hot sun
0 1
0 1 2 3
166.
Crave fatty or greasy foods
170.
Sunburn easily or suffer sun poisoning
0 1 2 3
0 1 2 3
167.
Low- or reduced-fat diet (0=never, 1=years ago,
171.
Muscles easily fatigued
0 1 2 3
0 1 2 3
2=within past year, 3=currently)
172.
Dry flaky skin or dandruff
0 1 2 3
168.
Tension headaches at base of skull
0 1 2 3
Section 7
39
173.
Awaken a few hours after falling asleep, hard to
180.
Headache if meals are skipped or delayed
0 1 2 3
0 1 2 3
get back to sleep
181.
Irritable before meals
0 1 2 3
174.
Crave sweets
182.
Shaky if meals delayed
0 1 2 3
0 1 2 3
175.
Binge or uncontrolled eating
183.
Family members with diabetes (0=none, 1=1 or
0 1 2 3
0 1 2 3
176.
Excessive appetite
2, 2=3 or 4, 3=more than 4)
0 1 2 3
177.
Crave coffee or sugar in the afternoon
184.
Frequent thirst
0 1 2 3
0 1 2 3
178.
Sleepy in afternoon
185.
Frequent urination
0 1 2 3
0 1 2 3
179.
Fatigue that is relieved by eating
0 1 2 3
Section 8
81
186.
Muscles become easily fatigued
200.
Can hear heart beat on pillow at night
0 1 2 3
0 1 2 3
187.
Feel exhausted or sore after moderate exercise
201.
Whole body or limb jerk as falling asleep
0 1 2 3
0 1 2 3
188.
Vulnerable to insect bites
202.
Night sweats
0 1 2 3
0 1 2 3
189.
Loss of muscle tone, heaviness in arms/legs
203.
Restless leg syndrome
0 1 2 3
0 1 2 3
190.
Enlarged heart or congestive heart failure
204.
Cracks at corner of mouth (Cheilosis)
0 1 2 3
0 1 2 3
191.
Pulse below 65 per minute (0=no, 1=yes)
205.
Fragile skin, easily chaffed, as in shaving
0 1 2 3
0 1 2 3
192.
Ringing in the ears (Tinnitus)
206.
Polyps or warts
0 1 2 3
0 1 2 3
193.
Numbness, tingling or itching in hands and feet
207.
MSG sensitivity
0 1 2 3
0 1 2 3
194.
Depressed
208.
Wake up without remembering dreams
0 1 2 3
0 1 2 3
195.
Fear of impending doom
209.
Small bumps on back of arms
0 1 2 3
0 1 2 3
196.
Worrier, apprehensive, anxious
210.
Strong light at night irritates eyes
0 1 2 3
0 1 2 3
197.
Nervous or agitated
211.
Nose bleeds and/or tend to bruise easily
0 1 2 3
0 1 2 3
198.
Feelings of insecurity
212.
Bleeding gums especially when brushing teeth
0 1 2 3
0 1 2 3
199.
Heart races
0 1 2 3
Section 9
78
213.
Tend to be a "night person"
226.
Arthritic tendencies
0 1 2 3
0 1 2 3
214.
Difficulty falling asleep
227.
Crave salty foods
0 1 2 3
0 1 2 3
215.
Slow starter in the morning
228.
Salt foods before tasting
0 1 2 3
0 1 2 3
216.
Tend to be keyed up, trouble calming down
229.
Perspire easily
0 1 2 3
0 1 2 3
217.
Blood pressure above 120/80
230.
Chronic fatigue, or get drowsy often
0 1 2 3
0 1 2 3
218.
Headache after exercising
231.
Afternoon yawning
0 1 2 3
0 1 2 3
219.
Feeling wired or jittery after drinking coffee
232.
Afternoon headache
0 1 2 3
0 1 2 3
220.
Clench or grind teeth
233.
Asthma, wheezing or difficulty breathing
0 1 2 3
0 1 2 3
221.
Calm on the outside, troubled on the inside
234.
Pain on the medial or inner side of the knee
0 1 2 3
0 1 2 3
222.
Chronic low back pain, worse with fatigue
235.
Tendency to sprain ankles or "shin splints"
0 1 2 3
0 1 2 3
223.
Become dizzy when standing up suddenly
236.
Tendency to need sunglasses
0 1 2 3
0 1 2 3
224.
Difficulty maintaining manipulative correction
237.
Allergies and/or hives
0 1 2 3
0 1 2 3
225.
Pain after manipulative correction
238.
Weakness, dizziness
0 1 2 3
0 1 2 3
Section 10
29
239.
Height over 6' 6" (0=no, 1=yes)
245.
Height under 4' 10" (0=no, 1=yes)
0 1
0 1
240.
Early sexual development (before age 10) (0=no,
246.
Decreased libido
0 1
0 1 2 3
1=yes)
247.
Excessive thirst
0 1 2 3
241.
Increased libido
248.
Weight gain around hips or waist
0 1 2 3
0 1 2 3
242.
Splitting type headache
249.
Menstrual disorders
0 1 2 3
0 1 2 3
243.
Memory failing
250.
Delayed sexual development (after age 13)
0 1 2 3
0 1
244.
Tolerate sugar, feel fine when eating sugar
(0=no, 1=yes)
0 1
(0=no, 1=yes)
251.
Tendency to ulcers or colitis
0 1 2 3
KEY: 0=No, symptom does not occur
2=Moderate symptom, occurs occasionally (weekly)
1=Yes, minor or mild symptom, rarely occurs (monthly)
3=Severe symptom, occurs frequently (daily)
®
©2003 Nutritional Therapy Association, Inc.
All Rights Reserved.
Nutritional Assessment Questionnaire 1.5
Page 4 of 4
Section 11
48
252.
Sensitive/allergic to iodine
260.
Mentally sluggish, reduced initiative
0 1 2 3
0 1 2 3
253.
Difficulty gaining weight, even with large
261.
Easily fatigued, sleepy during the day
0 1 2 3
0 1 2 3
appetite
262.
Sensitive to cold, poor circulation (cold hands
0 1 2 3
254.
Nervous, emotional, can't work under pressure
and feet)
0 1 2 3
255.
Inward trembling
263.
Constipation, chronic
0 1 2 3
0 1 2 3
256.
Flush easily
264.
Excessive hair loss and/or coarse hair
0 1 2 3
0 1 2 3
257.
Fast pulse at rest
265.
Morning headaches, wear off during the day
0 1 2 3
0 1 2 3
258.
Intolerance to high temperatures
266.
Loss of lateral 1/3 of eyebrow
0 1 2 3
0 1 2 3
259.
Difficulty losing weight
267.
Seasonal sadness
0 1 2 3
0 1 2 3
Section 12 – Men Only
27
268.
Prostate problems
272.
Waking to urinate at night
0 1 2 3
0 1 2 3
269.
Difficulty with urination, dribbling
273.
Interruption of stream during urination
0 1 2 3
0 1 2 3
270.
Difficult to start and stop urine stream
274.
Pain on inside of legs or heels
0 1 2 3
0 1 2 3
271.
Pain or burning with urination
275.
Feeling of incomplete bowel evacuation
0 1 2 3
0 1 2 3
276.
Decreased sexual function
0 1 2 3
Section 13 – Women Only
60
277.
Depression during periods
287.
Breast fibroids, benign masses
0 1 2 3
0 1 2 3
278.
Mood swings associated with periods (PMS)
288.
Painful intercourse (dysparenia)
0 1 2 3
0 1 2 3
279.
Crave chocolate around periods
289.
Vaginal discharge
0 1 2 3
0 1 2 3
280.
Breast tenderness associated with cycle
290.
Vaginal dryness
0 1 2 3
0 1 2 3
281.
Excessive menstrual flow
291.
Vaginal itchiness
0 1 2 3
0 1 2 3
282.
Scanty blood flow during periods
292.
Gain weight around hips, thighs and buttocks
0 1 2 3
0 1 2 3
283.
Occasional skipped periods
293.
Excess facial or body hair
0 1 2 3
0 1 2 3
284.
Variations in menstrual cycles
294.
Hot flashes
0 1 2 3
0 1 2 3
285.
Endometriosis
295.
Night sweats (in menopausal females)
0 1 2 3
0 1 2 3
286.
Uterine fibroids
296.
Thinning skin
0 1 2 3
0 1 2 3
Section 14
30
297.
Aware of heavy and/or irregular breathing
302.
Ankles swell, especially at end of day
0 1 2 3
0 1 2 3
298.
Discomfort at high altitudes
303.
Cough at night
0 1 2 3
0 1 2 3
299.
"Air hunger" or sigh frequently
304.
Blush or face turns red for no reason
0 1 2 3
0 1 2 3
300.
Compelled to open windows in a closed room
305.
Dull pain or tightness in chest and/or radiate
0 1 2 3
0 1 2 3
301.
Shortness of breath with moderate exertion
into right arm, worse with exertion
0 1 2 3
306.
Muscle cramps with exertion
0 1 2 3
Section 15
13
307.
Pain in mid-back region
310.
Cloudy, bloody or darkened urine
0 1 2 3
0 1 2 3
308.
Puffy around the eyes, dark circles under eyes
311.
Urine has a strong odor
0 1 2 3
0 1 2 3
309.
History of kidney stones (0=no, 1=yes)
0 1
Section 16
30
312.
Runny or drippy nose
317.
Never get sick (0 = sick only 1 or 2 times in last
0 1 2 3
0 1 2 3
313.
Catch colds at the beginning of winter
2 years, 1 = not sick in last 2 years, 2 = not
0 1 2 3
314.
Mucus producing cough
sick in last 4 years, 3 = not sick in last 7 years)
0 1 2 3
315.
Frequent colds or flu (0=1 or less per year, 1=2
318.
Acne (adult)
0 1 2 3
0 1 2 3
to 3 times per year, 2=4 to 5 times per year, 3=6
319.
Itchy skin (Dermatitis)
0 1 2 3
or more times per year)
320.
Cysts, boils, rashes
0 1 2 3
316.
Other infections (sinus, ear, lung, skin, bladder,
321.
History of Epstein Bar, Mono, Herpes,
0 1 2 3
0 1 2 3
kidney, etc.) (0=1 or less per year, 1=2 to 3
Shingles, Chronic Fatigue Syndrome, Hepatitis
times per year, 2=4 to 5 times per year, 3=6 or
or other chronic viral condition (0 = no, 1 = yes
more times per year)
in the past, 2 = currently mild condition, 3 =
severe)
KEY: 0=No, symptom does not occur
2=Moderate symptom, occurs occasionally (weekly)
1=Yes, minor or mild symptom, rarely occurs (monthly)
3=Severe symptom, occurs frequently (daily)
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