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Nutritional Assessment Questionnaire
Full Name:
First Name
Last Name
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example@example.com
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Year
Age:
Sex:
Male
Female
Please list the 5 major health concerns in your order of importance:
Blood Sugar
I crave sweets and eat them, and though I get a temporary boost of energy, I later crash
I feel shaky 2-3 hours after a meal
I eat a low-fat diet but can not seem to lose weight
If i miss a meal, I feel cranky and irritable, weak, or tired
If I eat a carbohydrate breakfast (muffin, bagel, cereal, pancakes etc..), I can't seem to control my eating for the rest of the day
Once I start eating sweets or carbohydrates, I can't seem to stop
If I eat fish or meat and vegetables, I feel good, but seem to get sleepy after eating a meal full of pasta, bread, potatoes, and dessert
I go for the breadbasket at restaurants
I get tired a few hours after eating
My memory and concentration are poor
I am tired most of the time
I have high blood pressure
I have type 2 diabetes
Inflammation
I feel poorly after eating (sluggishness, headaches, congestion, confusion, phlegm)
I have an auto-immune condition (fibromyalgia, rheumatoid arthritis, lupus)
I have colitis or inflammatory bowel disease
I have irritable bowel syndrome (spastic colon)
I exercise less than 30 minutes 3 times per week
Social History
How many alcoholic beverages do you consume per week?
How many times do you eat out per day?
Per week?
How many caffeinated beverages do you consume per day?
How many times a week do you eat fish?
How many times a week do you eat raw nuts or seeds?
Do you smoke?
Please Select
Yes
No
If yes, how many times per day?
How many times per week do you workout?
Please list all natural supplements you are currently taking and for what conditions?
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