Nutritional Assessment Questionnaire 1.

5
Name: _________________________________________________________

Date: _____/____/_____

Birth Date: __________________________

Gender: ______________

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

Notes:
1.
2.
3.
4.
5.

PART I
KEY:

Read the following questions and circle the number that applies:
0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly

2 = Consume or use weekly

3 = Consume or use daily

DIET

58

1.
2.
3.

0 1 2 3
0 1 2 3
0 1 2 3

4.
5.
6.

0 1 2 3
0 1 2 3
0 1 2 3

Alcohol
Artificial sweeteners
Candy, desserts, refined
sugar
Carbonated beverages
Chewing tobacco
Cigarettes

7.
8.
9.
10.
11.
12.
13.

0
0
0
0
0
0
0

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

Cigars/pipes
Caffeinated beverages
Fast foods
Fried foods
Luncheon meats
Margarine
Milk products

14.
15.
16.
17.
18.
19.
20.

0
0
0
0
0
0
0

1
1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

Radiation exposure (0=no, 1=yes)

Refined flour/baked goods
Vitamins and minerals
Water, distilled
Water, tap
Water, well
Diet often for weight control

LIFESTYLE
21.

0 1 2 3

22.
23.
24.

0 1 2 3
0 1 2 3
0 1 2 3

12

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
month)
Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)

MEDICATIONS
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.

0
0
0
0
0
0
0
0
0
0
0
0
0
0

Indicate any medications youre currently taking or have taken in the last month (0=no, 1=yes):

Antacids
Antianxiety medications
Antibiotics
Anticonvulsants
Antidepressants
Antifungals
Aspirin/Ibuprofen
Asthma inhalers
Beta blockers
Birth control pills/implant contraceptives
Chemotherapy
Cholesterol lowering medications
Cortisone/steroids
Diabetic medications/insulin

1
1
1
1
1
1
1
1
1
1
1
1
1
1

39.
40.

0 1
0 1

41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.

0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1

0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1

54

Diuretics
Estrogen or progesterone (pharmaceutical,
prescription)
Estrogen or progesterone (natural)
Heart medications
High blood pressure medications
Laxatives
Recreational drugs
Relaxants/Sleeping pills
Testosterone (natural or prescription)
Thyroid medication
Acetaminophen (Tylenol)
Ulcer medications
Sildenafal citrate (Viagra)

PART II (See key at bottom of page)

Section 1
52.
53.
54.
55.

0
0
0
0

1 2 3
1 2 3
1 2 3
1

56.
57.
58.
59.
60.

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

55

Belching or gas within one hour after eating

Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (no dairy, meat, fish or eggs) (0=no,
1=yes)
Bad breath (halitosis)
Loss of taste for meat
Sweat has a strong odor
Stomach upset by taking vitamins
Sense of excess fullness after meals

KEY: 0=No, symptom does not occur

1=Yes, minor or mild symptom, rarely occurs (monthly)

61.
62.
63.
64.
65.
66.
67.
68.
69.
70.

2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3

Feel like skipping breakfast

Feel better if you dont eat
Sleepy after meals
Fingernails chip, peel or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or tarry colored stools
Undigested food in stool

2=Moderate symptom, occurs occasionally (weekly)

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.
72.
73.
74.
75.
76.
77.
78.
79.
80.

0
0
0
0
0
0
0
0
0
0

81.
82.
83.

0 1
0 1 2 3
0 1

84.

0 1

1
1
1
1
1
1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

2
2
2
2

3
3
3
3

Pain between shoulder blades

Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car, airplane or motion sickness
History of morning sickness (0 = no, 1 = yes)
Light or clay colored stools
Dry skin, itchy feet or skin peels on feet
Headache over eyes
Gallbladder attacks (0=never, 1=years ago,
2=within last year, 3=within past 3 months)
Gallbladder removed (0=no, 1=yes)
Bitter taste in mouth, especially after meals
Become sick if you were to drink wine (0=no,
1=yes)
Easily intoxicated if you were to drink wine
(0=no, 1=yes)

85.

0 1

86.
87.
88.
89.
90.

0
0
0
0
0

91.

0 1 2 3

92.
93.
94.
95.
96.
97.
98.

0
0
0
0
0
0
0

1 2 3
1
1
1
1

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

Easily hung over if you were to drink wine (0=no,

1=yes)
Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14)
Recovering alcoholic (0=no, 1=yes)
History of drug or alcohol abuse (0=no, 1=yes)
History of hepatitis (0=no, 1=yes)
Long term use of prescription/recreational drugs
(0=no, 1=yes)
Sensitive to chemicals (perfume, cleaning
agents, etc.)
Sensitive to tobacco smoke
Exposure to diesel fumes
Pain under right side of rib cage
Hemorrhoids or varicose veins
Nutrasweet (aspartame) consumption
Sensitive to Nutrasweet (aspartame)
Chronic fatigue or Fibromyalgia

Section 3

47

99.
100.
101.

0 1 2 3
0 1 2 3
0 1

102.
103.
104.
105.
106.
107.

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

Food allergies
Abdominal bloating 1 to 2 hours after eating
Specific foods make you tired or bloated (0=no,
1=yes)
Pulse speeds after eating
Airborne allergies
Experience hives
Sinus congestion, "stuffy head"
Crave bread or noodles
Alternating constipation and diarrhea

108.

0 1 2 3

109.
110.
111.

0 1 2 3
0 1 2 3
0 1

112.
113.
114.
115.

0
0
0
0

Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotic for a total accumulated time of
(0=never, 1= <1 month, 2= <3 months, 3= >3
months)
Fungus or yeast infections
Ring worm, "jock itch", "athletes foot", nail fungus
Yeast symptoms increase with sugar, starch or
alcohol
Stools hard or difficult to pass
History of parasites (0=no, 1=yes)
Less than one bowel movement per day

126.

0 1 2 3

127.
128.
129.
130.
131.
132.
133.

0
0
0
0
0
0
0

134.
135.

0 1 2 3
0 1 2 3

1
1
1
1

2
2
2
2

3
3
3
3

Crohn's disease (0 =no, 1=yes in the past,

2=currently mild condition, 3=severe)
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up (0=no,
1=yes)
Asthma, sinus infections, stuffy nose
Bizarre vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

Section 4

58

116.
117.
118.
119.

0
0
0
0

120.
121.
122.

0 1 2 3
0 1 2 3
0 1 2 3

123.
124.
125.

0 1 2 3
0 1
0 1 2 3

1
1
1
1

2
2
2
2

3
3
3
3

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

Stools have corners or 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 lower bowel gas
Bad breath or strong body odors
Painful to press along outer sides of thighs
(Iliotibial Band)
Cramping in lower abdominal region
Dark circles under eyes

Section 5

75

136.
137.

0 1
0 1

138.
139.
140.

0 1
0 1 2 3
0 1

141.
142.
143.
144.
145.
146.
147.
148.
149.

0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1

2
2
2
2

3
3
3
3

2
2
2
2

3
3
3
3

History of carpal tunnel syndrome (0=no, 1=yes)

History of lower right abdominal pains or
ileocecal valve problems (0=no, 1=yes)
History of stress fracture (0=no, 1=yes)
Bone loss (reduced density on bone scan)
Are you shorter than you used to be? (0=no,
1=yes)
Calf, foot or toe cramps at rest
Cold sores, fever blisters or herpes lesions
Frequent fevers
Frequent skin rashes and/or hives
Herniated disc (0=no, 1=yes)
Excessively flexible joints, "double jointed"
Joints pop or click
Pain or swelling in joints
Bursitis or tendonitis

KEY: 0=No, symptom does not occur

1=Yes, minor or mild symptom, rarely occurs (monthly)

150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3
3

History of bone spurs (0=no, 1=yes)

Morning stiffness
Nausea with vomiting
Crave chocolate
Feet have a strong odor
History of anemia
Whites of eyes (sclera) blue tinted
Hoarseness
Difficulty swallowing
Lump in throat
Dry mouth, eyes and/or nose
Gag easily
White spots on fingernails
Cuts heal slowly and/or scar easily
Decreased sense of taste or smell

2=Moderate symptom, occurs occasionally (weekly)

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.
166.
167.

0 1
0 1 2 3
0 1 2 3

Experience pain relief with aspirin (0=no, 1=yes)

Crave fatty or greasy foods
Low- or reduced-fat diet (0=never, 1=years ago,
2=within past year, 3=currently)
Tension headaches at base of skull

169.
170.
171.
172.

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

Headaches when out in the hot sun

Sunburn easily or suffer sun poisoning
Muscles easily fatigued
Dry flaky skin or dandruff

168.

0 1 2 3

3
3
3
3
3
3

Awaken a few hours after falling asleep, hard to

get back to sleep
Crave sweets
Binge or uncontrolled eating
Excessive appetite
Crave coffee or sugar in the afternoon
Sleepy in afternoon
Fatigue that is relieved by eating

180.
181.
182.
183.

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

184.
185.

0 1 2 3
0 1 2 3

Headache if meals are skipped or delayed

Irritable before meals
Shaky if meals delayed
Family members with diabetes (0=none, 1=1 or
2, 2=3 or 4, 3=more than 4)
Frequent thirst
Frequent urination

3
3
3
3
3
3
3
3
3
3
3
3
3
3

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 per minute (0=no, 1=yes)
Ringing in the ears (Tinnitus)
Numbness, tingling or itching in hands and feet
Depressed
Fear of impending doom
Worrier, apprehensive, anxious
Nervous or agitated
Feelings of insecurity
Heart races

200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.

0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3

Can hear heart beat on pillow at night

Whole body or limb jerk as falling asleep
Night sweats
Restless leg syndrome
Cracks at corner of mouth (Cheilosis)
Fragile skin, easily chaffed, as in shaving
Polyps or warts
MSG sensitivity
Wake up without remembering dreams
Small bumps on back of arms
Strong light at night irritates eyes
Nose bleeds and/or tend to bruise easily
Bleeding gums especially when brushing teeth

3
3
3
3
3
3
3
3
3
3
3
3
3

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 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calm on the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction

226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.

0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3

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 the knee
Tendency to sprain ankles or "shin splints"
Tendency to need sunglasses
Allergies and/or hives
Weakness, dizziness

Height over 6' 6" (0=no, 1=yes)

Early sexual development (before age 10) (0=no,
1=yes)
Increased libido
Splitting type headache
Memory failing
Tolerate sugar, feel fine when eating sugar
(0=no, 1=yes)

245.
246.
247.
248.
249.
250.

0
0
0
0
0
0

1
1
1
1
1
1

251.

0 1 2 3

Section 7

39

173.

0 1 2 3

174.
175.
176.
177.
178.
179.

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

Section 8
186.
187.
188.
189.
190.
191.
192.
193.
194.
195.
196.
197.
198.
199.

0
0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2

81

Section 9
213.
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.

0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2

78

Section 10
239.
240.

0 1
0 1

241.
242.
243.
244.

0
0
0
0

1 2 3
1 2 3
1 2 3
1

29

KEY: 0=No, symptom does not occur

1=Yes, minor or mild symptom, rarely occurs (monthly)

2
2
2
2

3
3
3
3

Height under 4' 10" (0=no, 1=yes)

Decreased libido
Excessive thirst
Weight gain around hips or waist
Menstrual disorders
Delayed sexual development (after age 13)
(0=no, 1=yes)
Tendency to ulcers or colitis

2=Moderate symptom, occurs occasionally (weekly)

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
252.
253.

0 1 2 3
0 1 2 3

254.
255.
256.
257.
258.
259.

0
0
0
0
0
0

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

48

Sensitive/allergic to iodine
Difficulty gaining weight, even with large
appetite
Nervous, emotional, can't work under pressure
Inward trembling
Flush easily
Fast pulse at rest
Intolerance to high temperatures
Difficulty losing weight

260.
261.
262.

0 1 2 3
0 1 2 3
0 1 2 3

263.
264.
265.
266.
267.

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

Mentally sluggish, reduced initiative

Easily fatigued, sleepy during the day
Sensitive to cold, poor circulation (cold hands
and feet)
Constipation, chronic
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the day
Loss of lateral 1/3 of eyebrow
Seasonal sadness

272.
273.
274.
275.
276.

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

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

287.
288.
289.
290.
291.
292.
293.
294.
295.
296.

0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3

Breast fibroids, benign masses

Painful intercourse (dysparenia)
Vaginal discharge
Vaginal dryness
Vaginal itchiness
Gain weight around hips, thighs and buttocks
Excess facial or body hair
Hot flashes
Night sweats (in menopausal females)
Thinning skin

Section 12 Men Only

268.
269.
270.
271.

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

27

Prostate problems
Difficulty with urination, dribbling
Difficult to start and stop urine stream
Pain or burning with urination

Section 13 Women Only

277.
278.
279.
280.
281.
282.
283.
284.
285.
286.

0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3

60

Depression during periods

Mood swings associated with periods (PMS)
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

Section 14
297.
298.
299.
300.
301.

0
0
0
0
0

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

30

Aware of heavy and/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

302.
303.
304.
305.

0
0
0
0

306.

0 1 2 3

Ankles swell, especially at end of day

Cough at night
Blush or face turns red for no reason
Dull pain or tightness in chest and/or radiate
into right arm, worse with exertion
Muscle cramps with exertion

Pain in mid-back region

Puffy around the eyes, dark circles under eyes
History of kidney stones (0=no, 1=yes)

310.
311.

0 1 2 3
0 1 2 3

Cloudy, bloody or darkened urine

Urine has a strong odor

Runny or drippy nose

Catch colds at the beginning of winter
Mucus producing cough
Frequent colds or flu (0=1 or less per year, 1=2
to 3 times per year, 2=4 to 5 times per year, 3=6
or more times per year)
Other infections (sinus, ear, lung, skin, bladder,
kidney, etc.) (0=1 or less per year, 1=2 to 3
times per year, 2=4 to 5 times per year, 3=6 or
more times per year)

317.

0 1 2 3

318.
319.
320.
321.

0
0
0
0

Never get sick (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)
Acne (adult)
Itchy skin (Dermatitis)
Cysts, boils, rashes
History of Epstein Bar, Mono, Herpes,
Shingles, Chronic Fatigue Syndrome, Hepatitis
or other chronic viral condition (0 = no, 1 = yes
in the past, 2 = currently mild condition, 3 =
severe)

1
1
1
1

2
2
2
2

3
3
3
3

Section 15
307.
308.
309.

0 1 2 3
0 1 2 3
0 1

13

Section 16
312.
313.
314.
315.

0
0
0
0

316.

0 1 2 3

1
1
1
1

2
2
2
2

3
3
3
3

30

KEY: 0=No, symptom does not occur

1=Yes, minor or mild symptom, rarely occurs (monthly)

1
1
1
1

2
2
2
2

3
3
3
3

2=Moderate symptom, occurs occasionally (weekly)

3=Severe symptom, occurs frequently (daily)

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