Nutrient Deficiency Assessment
Name
*
First Name
Last Name
Email
*
example@example.com
Nutrient Score
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How often do you feel tired or weak, even after a full night's sleep?
*
Rarely
Sometimes
Frequently
Have you noticed brittle nails, dry skin, or thinning hair?
*
No
Occasionally
Frequently
Do you frequently experience muscle cramps or joint pain?
*
No
Occasionally
Frequently
How balanced is your diet (are you getting vegetables, fruits, and proteins daily)?
*
Very Balanced
Moderately Balanced
How often do you follow restrictive diets (such as vegan, keto, etc.)?
*
Never
Sometimes
Regularly, without supplementation
Have you been experiencing frequent headaches or dizziness?
*
No
Occasionally
Yes
Do you have difficulty concentrating or often feel foggy-headed?
*
Rarely
Occasionally
Frequently
Have you noticed unusual bruising or slower wound healing than usual?
*
No
Occasionally
Frequently
Do you suffer from digestive issues, such as constipation or diarrhea?
*
No
Sometimes
Frequently
How often do you experience tingling or numbness in your hands or feet?
*
Never
Occasionally
Often
Have you experienced frequent infections or a weakened immune system?
*
No
Occasionally
Frequently
How would you describe your energy levels throughout the day?
*
High
Moderate
Low
Have you noticed changes in your vision, such as blurriness or difficulty seeing at night?
*
No
Occasionally
Frequently
How often do you eat fortified foods or take vitamin/mineral supplements?
*
Daily
Occasionally
Rarely or never
Nutrient Score
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