"Optimum Nutrition Questionnaire Template"

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Your Optimum Supplement Program
Optimum Nutrition Questionnaire
Symptom Analysis
For each symptom that you experience often, score 1 point. Many symptoms occur more than once,
because they can be the result of many nutrient deficiencies. If you experience any of the symptoms in
bold type, score 2 points. The maximum score for each nutrient is 10 points. Put your score for each
nutrient in the box.
VITAMIN A
VITAMIN D
Mouth ulcers
Arthritis or osteoporosis
Poor night vision
Backache
Acne
Tooth decay
Frequent colds or infections
Hair loss
Dry flaky skin
Muscle twitching or spasms
Dandruff
Joint pain or stiffness
Thrush or cystitis
Weak bones
Diarrhea
YOUR SCORE
YOUR SCORE
VITAMIN B2
VITAMIN E
Bloodshot, burning, or gritty
Lack of sex drive
eyes
Exhaustion after light exercise
Sensitivity to bright lights
Easy bruising
Sore tongue
Slow wound healing
Cataracts
Varicose veins
Dull or oily hair
Poor skin elasticity
Eczema or dermatitis
Loss of muscle tone
Split nails
Infertility
Cracked lips
YOUR SCORE
YOUR SCORE
VITAMIN C
VITAMIN B3 (NIACIN)
Frequent colds
Lack of energy
Lack of energy
Diarrhea
Frequent infections
Insomnia
Bleeding or tender gums
Headaches or migraines
Easy bruising
Poor memory
Nose bleeds
Anxiety or tension
Slow wound healing
Depression
Red pimples on skin
Irritability
Your Optimum Supplement Program
Optimum Nutrition Questionnaire
Symptom Analysis
For each symptom that you experience often, score 1 point. Many symptoms occur more than once,
because they can be the result of many nutrient deficiencies. If you experience any of the symptoms in
bold type, score 2 points. The maximum score for each nutrient is 10 points. Put your score for each
nutrient in the box.
VITAMIN A
VITAMIN D
Mouth ulcers
Arthritis or osteoporosis
Poor night vision
Backache
Acne
Tooth decay
Frequent colds or infections
Hair loss
Dry flaky skin
Muscle twitching or spasms
Dandruff
Joint pain or stiffness
Thrush or cystitis
Weak bones
Diarrhea
YOUR SCORE
YOUR SCORE
VITAMIN B2
VITAMIN E
Bloodshot, burning, or gritty
Lack of sex drive
eyes
Exhaustion after light exercise
Sensitivity to bright lights
Easy bruising
Sore tongue
Slow wound healing
Cataracts
Varicose veins
Dull or oily hair
Poor skin elasticity
Eczema or dermatitis
Loss of muscle tone
Split nails
Infertility
Cracked lips
YOUR SCORE
YOUR SCORE
VITAMIN C
VITAMIN B3 (NIACIN)
Frequent colds
Lack of energy
Lack of energy
Diarrhea
Frequent infections
Insomnia
Bleeding or tender gums
Headaches or migraines
Easy bruising
Poor memory
Nose bleeds
Anxiety or tension
Slow wound healing
Depression
Red pimples on skin
Irritability
YOUR SCORE
Bleeding or tender gums
Acne
VITAMIN B1
YOUR SCORE
Tender muscles
Eye pains
VITAMIN B5
Irritability
Muscle tremors, cramps, or spasms
Poor concentration
Apathy
"Prickly" legs
Poor concentration
Poor memory
Burning feet or tender heels
Stomach pains
Nausea or vomiting
Constipation
Lack of energy
Tingling hands
Exhaustion after light exercise
Rapid heartbeat
Anxiety or tension
YOUR SCORE
Teeth grinding
YOUR SCORE
MAGNESIUM
Muscle cramps, tremors, or
MANGANESE
spasms
Muscle twitches
Muscle weakness
Childhood "growing pains"
Insomnia, nervousness, or
Dizziness or poor sense of
hyperactivity
balance
High blood pressure
Fits or convulsions
Irregular or rapid heartbeat
Sore knees
Constipation
YOUR SCORE
Fits or convulsions
Breast tenderness or water
SELENIUM
retention
Family history of cancer
Depression or confusion
Signs of premature aging
YOUR SCORE
Cataracts
High blood pressure
ZINC
YOUR SCORE
Decline in sense of taste or
smell
CHROMIUM
White marks on more than two
Excessive or cold sweats
finger nails
Dizziness or irritability after six
Frequent infections
hours without food
Stretch marks
Need for frequent meals
Acne or greasy skin
Cold hands
YOUR SCORE
Need for excessive sleep or
drowsiness during the day
YOUR SCORE
Essential Fatty Acid Profile
OMEGA 3 OMEGA 6
Dry skin, eczema, or dry eyes
Frequent infections
Dry hair or dandruff
Poor memory or learning
Inflammatory health problems,
difficulties
e.g., arthritis
High blood pressure or high
Excessive thirst or sweating
blood lipids
PMS or breast pain
YOUR SCORE
Omega 6 deficiency signs
 Do
you
have high blood pressure?

Do you suffer from
PMS
or
breast
pain?
 Do
you suffer
from
eczema or
dry skin?
 Do
you suffer from
dry
eyes?
 Do
you
have
an
inflammatory
health
problem,
like
arthritis?
 Do
you
have difficulty losing
weight?
 Do
you
have
a
blood sugar problem
or diabetes?
 Do
you
have multiple
sclerosis?
 Do
you
drink
alcohol
every
day?
 Do
you
have
any
mental health
problems?

Do you suffer
from
excessive
thirst?
How
did you
score?
Five or more "yes" answers indicate
that
you may
be
deficient in
Omega 6 fats.
Check your
diet
carefully for the foods
listed
below.
This family of fats comes exclusively from
seeds
and
their
oils.
The best are hemp, pumpkin,
sunflower,
safflower, sesame,
corn, walnut,
soybean,
and wheat germ oil. About
half
of
the
fats
in
these
oils come
from the Omega
6 family,
mainly
as
linoleic
acid.
An optimal intake would
be
one
to
two tablespoons
of oil a day, or two
to three tablespoons
of ground
seeds.
Omega 3 deficiency signs
 Do
you
have dry skin?
 Do
you
have
any
inflammatory health
problems?
 Do
you suffer from water
retention?
 Do
you get
tingling in the
arms or legs?
 Do
you
have high blood pressure
or
high
triglycerides
(the
name for fat in the
blood)?
 Are
you
prone to infections?
 Are
you
finding it harder to lose
weight?
 Have
your
memory
and
learning
ability
declined?
 Do
you suffer
from
a lack of coordination or
impaired
vision?
 If
you are a child, are you small
for
your age or growing slowly?
How
did you
score?
Five or more
"yes"
answers
indicates
that you
may
be deficient
in Omega
3 fats.
Check your
diet
carefully for the foods
listed
below.
The best seed oils for Omega 3 fats are flax (also known as linseed), hemp, pumpkin, and chia.
Now put all your individual scores into appropriate spaces in the second column (headed Symptom
Score) of the chart on p.
244.
Lifestyle Analysis
The following checks allow you to adjust your nutrient needs according to aspects of your health and
lifestyle. Again, answer the questions as best you can and work out your score. In most checks the
maximum score is 10, scoring 1 point for each "yes" answer unless otherwise specified. If you score 5
or more in any category, you will need to add the points shown in the chart on p. 244 to your
individual nutrient scores. The easiest way to do this is to circle all the numbers in the corresponding
columns on p. 244. For example, if you scored more than 5 on the Energy check, you would circle all the
numbers in the energy column on p. 244.
Some checks are either "yes" or "no." If you answer "yes," circle the numbers in the relevant
columns on p. 244.
Energy Check
___
Do you need more than eight hours' sleep a night?
___
Are you rarely wide awake and raring to go within twenty minutes of rising?
___
Do you need something to get you going in the morning, like a cup of tea or coffee or a
cigarette?
___
Do you have tea, coffee, sugar-containing foods or drinks, or smoke cigarettes, at
regular intervals during the day?
___
Do you often feel drowsy or sleepy during the day, or after meals?
___
Do you get dizzy or irritable if you have not eaten for six hours?
___
Do you avoid exercise because you do not have the energy?
___
Do you sweat a lot during the night or day or get excessively thirsty?
___
Do you sometimes lose concentration or does your mind go blank?
___
Is your energy less now than it used to be?
YOUR SCORE
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