Brain Health and Nutrition Assessment Form (BHNAF)

Brain Health and Nutrition Assessment Form™ (BHNAF)
Full Name

First Name Last Name
Age
Gender

Male Female
Date

Month Day Year
Phone Number

Area Code Phone Number
Email
example@example.com
Please check the appropriate number on all questions below. 0 as the least/never and 3 as the most/always.
Section 1
Low brain endurance for focus and concentration

0 1 2 3
Cold hands and feet

0 1 2 3
Must exercise or drink coffee to improve brain function

0 1 2 3
Poor nail health

0 1 2 3
Fungal growth on toenails

0 1 2 3
Must wear socks at night

0 1 2 3
Nail beds are white instead of pink

0 1 2 3
The tip of the nose is cold

0 1 2 3
Section 2
Irritable, nervous, shaky, or light-headed between meals

0 1 2 3
Feel energized after meals

0 1 2 3
Difficulty eating large meals in the morning

0 1 2 3
Energy level drops in the afternoon

0 1 2 3
Crave sugar and sweets in the afternoon

0 1 2 3
Wake up in the middle of the night

0 1 2 3
Difficulty concentrating before eating

0 1 2 3
Depend on coffee to keep going

0 1 2 3
Section 3
Fatigue after meals

0 1 2 3
Sugar and sweet cravings after meals

0 1 2 3
Need for a stimulant, such as coffee, after meals

0 1 2 3
Difficulty losing weight

0 1 2 3
Increased frequency of urination

0 1 2 3
Difficulty falling asleep

0 1 2 3
Increased appetite

0 1 2 3
Section 4
Always have projects and things that need to be done

0 1 2 3
Never have time for yourself

0 1 2 3
Not getting enough sleep or rest

0 1 2 3
Difficulty getting regular exercise

0 1 2 3
Feel that you are not accomplishing your life’s purpose

0 1 2 3
Section 5
Dry and unhealthy skin

0 1 2 3
Dandruff or a flaky scalp

0 1 2 3
Consumption of processed foods that are bagged or boxed

0 1 2 3
Consumption of fried foods

0 1 2 3
Difficulty consuming raw nuts or seeds

0 1 2 3
Difficulty consuming fish (not fried)

0 1 2 3
Difficulty consuming olive oil, avocados, flax seed oil, or natural fats

0 1 2 3
Section 6
Difficulty digesting foods

0 1 2 3
Constipation or inconsistent bowel movements

0 1 2 3
Increased bloating or gas

0 1 2 3
Abdominal distention after meals

0 1 2 3
Difficulty digesting protein-rich foods

0 1 2 3
Difficulty digesting starch-rich foods

0 1 2 3
Difficulty digesting fatty or greasy foods

0 1 2 3
Difficulty swallowing supplements or large bites of food

0 1 2 3
Abnormal gag reflex

Yes No
Section 7
Brain fog (unclear thoughts or concentration)

Yes No
Pain and inflammation

Yes No
Noticeable variations in mental speed

Yes No
Brain fatigue after meals

0 1 2 3
Brain fatigue after exposure to chemicals, scents, or pollutants

0 1 2 3
Brain fatigue when the body is inflamed

0 1 2 3
Section 8
Grain consumption leads to tiredness

0 1 2 3
Grain consumption makes it difficult to focus and concentrate

0 1 2 3
Feel better when bread and grains are avoided

0 1 2 3
Grain consumption causes the development of any symptoms

0 1 2 3
A 100% gluten-free diet

Yes No
Section 9
A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease

Yes No
Family members who have been diagnosed with an autoimmune disease

Yes No
Family members who have been diagnosed with celiac disease or gluten sensitivity

Yes No
Changes in brain function with stress, poor sleep, or immune activation

0 1 2 3
Section 10
A loss of pleasure in hobbies and interests

0 1 2 3
Feel overwhelmed with ideas to manage

0 1 2 3
Feelings of inner rage or unprovoked anger

0 1 2 3
Feelings of paranoia

0 1 2 3
Feelings of sadness for no reason

0 1 2 3
A loss of enjoyment in life

0 1 2 3
A lack of artistic appreciation

Yes No
Feelings of sadness in overcast weather

0 1 2 3
A loss of enthusiasm for favorite activities

0 1 2 3
A loss of enjoyment in favorite foods

0 1 2 3
A loss of enjoyment in friendships and relationships

0 1 2 3
Inability to fall into deep, restful sleep

0 1 2 3
Feelings of dependency on others

0 1 2 3
Feelings of susceptibility to pain

0 1 2 3
Section 11
Feelings of worthlessness

0 1 2 3
Feelings of hopelessness

0 1 2 3
Self-destructive thoughts

0 1 2 3
Inability to handle stress

0 1 2 3
Anger and aggression while under stress

0 1 2 3
Feelings of tiredness, even after many hours of sleep

0 1 2 3
A desire to isolate yourself from others

0 1 2 3
An unexplained lack of concern for family and friends

0 1 2 3
An inability to finish tasks

0 1 2 3
Feelings of anger for minor reasons

0 1 2 3
Section 12
A decrease in visual memory (shapes and images)

Yes No
A decrease in verbal memory

0 1 2 3
Occurrence of memory lapses

0 1 2 3
A decrease in creativity

0 1 2 3
A decrease in comprehension

0 1 2 3
Difficulty calculating numbers

0 1 2 3
Difficulty recognizing objects and faces

0 1 2 3
A change in opinion about yourself

0 1 2 3
Slow mental recall

0 1 2 3
Section 13
A decrease in mental alertness

0 1 2 3
A decrease in mental speed

0 1 2 3
A decrease in concentration quality

0 1 2 3
Slow cognitive processing

0 1 2 3
Impaired mental performance

0 1 2 3
An increase in the ability to be distracted

0 1 2 3
Need coffee or caffeine sources to improve mental function

0 1 2 3
Section 14
Feelings of nervousness or panic for no reason

0 1 2 3
Feelings of dread

0 1 2 3
Feelings of a “knot” in your stomach

0 1 2 3
Feelings of being overwhelmed for no reason

0 1 2 3
Feelings of guilt about everyday decisions

0 1 2 3
A restless mind

0 1 2 3
An inability to turn off the mind when relaxing

0 1 2 3
Disorganized attention

0 1 2 3
Worry over things never thought about before

0 1 2 3
Feelings of inner tension and inner excitability

0 1 2 3
Should be Empty:

Brain Health and Nutrition Assessment Form™ (BHNAF)

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Section 8

Section 9

Section 10

Section 11

Section 12

Section 13

Section 14