Nutritional Assessment Questionnaire

Nutritional Assessment Questionnaire

Name: ______Date: _____/____/_____

Address: ______Phone: ______

Date of Birth: ______Weight:______Height: ______

Blood Group: ______

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

PART I

Read the following questions and fill in the number that applies:

KEY: / 0 (or leave blank) = Do not consume or use
1 = Consume or use 2-3 times/month / 2 = Consume or use weekly
3 = Consume or use daily

DIET

  1. _____ Alcohol
  2. _____ Artificial sweeteners
  3. _____ Candy or other sweets
  4. _____ Carbonated beverages
  5. _____ Chewing tobacco
  6. _____ Cigarettes
  7. _____ Cigars/pipes
/
  1. _____ Coffee
  2. _____ Eat fast food regularly
  3. _____ Fried foods
  4. _____ Luncheon meats/ hot dogs
  5. _____ Margarine
  6. _____ Milk products
  7. _____ Non-herbal tea
/
  1. _____ Refined flour/ Baked goods
  2. _____ Refined sugar
  3. _____ Vitamins and minerals
  4. _____ Water, distilled
  5. _____ Water, Tap
  6. _____ Water, well
  7. _____ Diet often

LIFESTYLE

  1. _____ Times you exercise per week (1 = once a week, 2 = 2-4 times/week, 3 = 5 times a week)
  2. _____ Changed jobs (3= within last 2 months, 2= within last 6 months, 1= within last 12 months.)
  1. _____ Divorced (3= within last 6 months, 2= within last year, 1= within last 2 years)
  2. _____ Work over 60 hours/week (3= always, 2= usually, 1= occasionally, 0= never)

MEDICATIONS
Indicate with a checkmark or circle any medications you’re currently taking or have taken in the last month:

  1. _____ Antacids
  2. _____ Antibiotics
  3. _____ Anticonvulsants
  4. _____ Antidepressants
  5. _____ Antifungals
  6. _____ Aspirin/Ibuprofen
/
  1. _____ Asthma inhalers
  2. _____ Beta blockers
  3. _____ Chemotherapy
  4. _____ Cortisone
  5. _____ Diabetic medications
  6. _____ Diuretics
/
  1. _____ Estrogen/Progesterone
  2. _____ Heart medications
  3. _____ High blood pressure
  4. _____ Hormone Therapy
  5. _____ Laxatives
  6. _____ Insulin
/
  1. _____ Oral/implant contraceptives
  2. _____ Radiation exposure
  3. _____ Recreational drugs
  4. _____ Relaxants/Sleeping pills
  5. _____ Thyroid medication
  6. _____ Tylenol/acetaminophen
  7. _____ Ulcer medications

Other medications and dosages (if known): ______

Recent Operations/illnesses:______

______

PART II

Read the following questions and fill in the number that applies:
(How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY: / 0 (or leave blank) = No or Do not have the symptom, the symptom does not occur
1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)
2 = It is a moderate symptom or it occasionally occurs (weekly)
3 = It is a severe symptom or it frequently occurs (daily)

Section 1

  1. _____ Belching or gas within 1 hr. of a meal
  2. _____ Heartburn or acid reflux
  3. _____ Bloating shortly after eating
  4. _____ Are you a vegan (no dairy, meat, fish or eggs)
  5. _____ Bad breath (halitosis)
  6. _____ Loss of taste for meat
  7. _____ Sweat has a strong odor
  8. _____ Stomach upset by taking vitamins
  9. _____ Sense of excess fullness after meals
/
  1. _____ Do you feel like skipping breakfast?
  2. _____ Do you feel better if you don’t eat?
  3. _____ Sleepy after meals
  4. _____ Fingernails chip, peel or break easily
  5. _____ Anemia unresponsive to iron
  6. _____ Stomach pains or cramps
  7. _____ Diarrhea, chronic
  8. _____ Diarrhea shortly after meals
  9. _____ Black or tarry stools
  10. _____ Undigested food in stool

Section 2

  1. _____ Pain between shoulder blades
  2. _____ Stomach upset by greasy foods
  3. _____ Greasy or shiny stools
  4. _____ Nausea
  5. _____Sea, car or airplane sickness, motion sickness
  6. _____ History of morning sickness (1 = yes, 0 = no)
  7. _____ Light or clay colored stools
  8. _____ Dry skin, itchy feet and/or skin peels on feet
  9. _____ Headache over the eye
  10. _____ Gallbladder attacks (past or present)
  11. _____ Gallbladder removed (1 = yes, 0 = no)
  12. _____ Bitter taste in mouth, especially after meals
  13. _____ Become sick if drinking wine
  14. _____ If drinking alcohol, easily intoxicated
/
  1. _____ Alcoholic beverages per week (0 = < 3/ week, 1 = < 7/ week,
    2 = < 14/ week, 3 = > 14/week)
  2. _____ Recovering alcoholic (1 = yes, 0 = no)
  3. _____ Hangovers after drinking alcohol
  4. _____ History of drug or alcohol abuse (1 = yes, 0 = no)
  5. _____ History of hepatitis (1 = yes, 0 = no)
  6. _____ Long term use of prescription medications (1 = yes, 0 =no)
  7. _____ Sensitive to chemicals (perfume, cleaning solvents, insecticides, exhaust, etc.)
  8. _____ Sensitive to tobacco smoke
  9. _____ Exposure to diesel fumes
  10. _____ Pain under right side of rib cage
  11. _____ Hemorrhoids or varicose veins
  12. _____ Nutrasweet (aspartame) consumption
  13. _____ Bothered by aspartame (Nutrasweet)
  14. _____ Chronic fatigue or Fibromyalgia

Section 3

  1. _____ Food allergies
  2. _____ Abdominal bloating 1 to 2 hours after eating
  3. _____ Specific foods make you tired or bloated (1= yes, 0= no)
  4. _____ Pulse speeds after eating
  5. _____ Airborne allergies
  6. _____ Experience hives
  7. _____ Sinus congestion, "stuffy head"
  8. _____ Crave bread or noodles
  9. _____ Alternating constipation and diarrhea
/
  1. _____ Crohn's disease (1 = yes, 0 = no)
  2. _____ Wheat or grain sensitivity
  3. _____ Dairy sensitivity
  4. _____ Are there foods you could not give up (1 = yes, 0 = no)
  5. _____ Asthma, sinus infections, stuffy nose
  6. _____ Bizarre vivid or nightmarish dreams
  7. _____ Use over-the-counter pain medications
  8. _____ Feel spacey or unreal

Section 4

  1. _____ Anus itches
  2. _____ Coated tongue
  3. _____ Feel worse in moldy or musty place
  4. _____ Taken any antibiotic for a combined time of
    (1 = < 1 mo., 2 = < 3 mos., 3 = > 3 mos.)
  5. _____ Fungus or yeast infections
  6. _____ Ring worm, "jock itch", "athletes foot", nail fungus
  7. _____ Eating sugar, starch or drinking alcohol increases yeast symptoms
  8. _____ Stools hard or difficult to pass
  9. _____ History of parasites (1 = yes, 0 = no)
/
  1. _____ Less than one bowel movement per day
  2. _____ Stools have corners or edges are flat or ribbon shaped
  3. _____ Stools are not well formed (loose)
  4. _____ Irritable bowel or mucus colitis
  5. _____ Blood in stool
  6. _____ Mucus in stool
  7. _____ Excessive foul smelling lower bowel gas
  8. _____ Bad breath or strong body odors
  9. _____ Painful to press along outer sides of thighs(Iliotibial Band)
  10. _____ Cramping in lower abdominal region
  11. _____ Dark circles under eyes

Section 5

  1. _____ History of Carpal Tunnel Syndrome (1 = yes, 0 = no)
  2. _____ History of lower right abdominal pain (1 = yes, 0 = no)
  3. _____ History of stress fractures
  4. _____ Bone loss (reduced density on bone scan)
  5. _____ Are you shorter than you used to be? (1 = yes, 0 = no)
  1. _____ Calf, foot or toe cramps at rest
  2. _____ Cold sores, fever blisters or herpes lesions
  3. _____ Frequent fevers
  4. _____ Frequent skin rashes and / or hives
  5. _____ Have you ever had a herniated disc? (1 = yes, 0 = no)
  6. _____ Excessively flexible joints, "double jointed"
  7. _____ Joints pop or click
  8. _____ Pain or swelling in joints
  9. _____ Bursitis or tendonitis
  10. _____ History of bone spurs (1 = yes, 0 = no)
/
  1. _____ Morning stiffness
  1. _____ Vomiting or nausea
  2. _____ Crave chocolate
  3. _____ Feet have a strong odor
  4. _____ Tendency to anemia
  5. _____ Whites of eyes (sclera) blue tinted
  6. _____ Hoarseness
  7. _____ Difficulty swallowing
  8. _____ Lump in throat
  9. _____ Dry mouth, eyes and / or nose
  10. _____ Gag easily
  11. _____ White spots on fingernails
  12. _____ Cuts heal slowly and / or scar easily
  13. _____ Decreased sense of taste or smell

Section 6

  1. _____ Aspirin is an effective pain reliever (1 = yes, 0 = no)
  2. _____ Crave fatty or greasy foods
  3. _____ Low or reduced fat diet (past or present)
  1. _____ Tension headaches at base of skull
/
  1. _____ Headaches when out in the hot sun
  2. _____ Sunburn easily or suffer sun poisoning
  3. _____ Muscles easily fatigued
  4. _____ Dry flaky skin and or dandruff

Section 7

  1. _____ Awaken a few hours after falling asleep, hard to get back to sleep
  2. _____ Crave sweets
  3. _____ Eat desserts or sugary snacks
  4. _____ Binge or uncontrolled eating
  5. _____ Excessive appetite
  6. _____ Crave coffee or sugar in the afternoon
  1. _____ Sleepy in afternoon
/
  1. _____ Fatigue that is relieved by eating
  2. _____ Headache if meals are skipped or delayed
  3. _____ Irritable before meals
  4. _____ Shaky if meals delayed
  5. _____ Family members with diabetes (0 = none, 1 = 2 or less,
    2 = Between 2 - 4, 3 = More than 4)
  6. _____ Frequent thirst
  7. _____ Frequent urination

Section 8

185. _____ Muscles become easily fatigued
  1. _____ Feel worse, sore after moderate exercise
  2. _____ Vulnerable to insect bites
  3. _____ Loss of muscle tone, heaviness in arms / legs
  4. _____ Enlarged heart, or heart failure
  5. _____ Pulse slow / below 65 (1 = yes, 0 = no)
  6. _____ Ringing in the ears / Tinnitus
  7. _____ Numbness, tingling or itching in extremities
  8. _____ Depressed
  9. _____ Fear of impending doom
  10. _____ Worrier, apprehensive, anxious
  11. _____ Nervous or agitated
  12. _____ Feelings of insecurity
  1. _____ Heart races
/
  1. _____ Can hear heart beat on pillow at night
  2. _____ Whole body or limb jerk as falling asleep
  3. _____ Night sweats
  4. _____ Restless leg syndrome
  5. _____ Cheilosis (cracks at corner of mouth)
  6. _____ Fragile skin, easily chaffed, as in shaving
  7. _____ Polyps or warts
  8. _____ MSG sensitivity
  9. _____ Wake up without remembering dreams
  10. _____ Take birth control pills
  11. _____ Small bumps on back of arms
  12. _____ Strong light at night irritates eyes
  13. _____ Nose bleeds and / or tend to bruise easily
  14. _____ Bleeding gums especially when brushing teeth

Section 9

  1. _____ Tend to be a "night person"
  2. _____ Difficulty falling asleep
  3. _____ Slow starter in the morning
  4. _____ Keyed up, trouble calming down
  1. _____ High blood pressure (normal 120/80)
  2. _____ Headache after exercising
  3. _____ Feeling wired or jittery if drinking coffee
  4. _____ Clench or grind teeth
  5. _____ Calm on the outside, troubled inside
  6. _____ Chronic low back pain, worse with fatigue
  7. _____ Become dizzy when standing up suddenly
  8. _____ Difficult maintaining manipulative correction
  9. _____ Pain after manipulative correction
/
  1. _____ Arthritic tendencies
  2. _____ Crave salty foods
  3. _____ Salt foods before tasting
  4. _____ Perspire easily
  5. _____ Chronic fatigue, or get drowsy often
  6. _____ Afternoon yawning
  7. _____ Afternoon headache
  8. _____ Asthma, wheezing or difficulty breathing
  9. _____ Pain on the medial or inner side of the knee
  10. _____ Tendency to sprain ankles or "shin splints"
  11. _____ Tendency to need to wear sunglasses
  12. _____ Allergies and / or hives
  13. _____ Weakness, dizziness

Section 10

  1. _____ Over 6' 6" tall (Mature height)
  2. _____ Early sexual development (before age 10) (1 = yes, 0 = no)
  3. _____ Increased libido
  4. _____ Splitting type headache
  5. _____ Memory failing
  6. _____ Ability to tolerate sugar
/
  1. _____ Under 4' 10" (Mature height)
  2. _____ Decreased libido
  3. _____ Abnormal thirst
  4. _____ Weight gain around hips or waist
  5. _____ Menstrual disorders
  6. _____ Delayed (after age 13) sexual development (1 = yes, 0 = no)
  7. _____ Tendency to ulcers or colitis

Section 11

  1. _____ Allergic to iodine
  2. _____ Difficulty gaining weight, even with large appetite
  3. _____ Nervous, emotional, can't work under pressure
  4. _____ Inward trembling
  5. _____ Flush easily
  6. _____ Fast pulse at rest
  7. _____ Intolerance to high temperatures
  8. _____ Difficulty losing weight
/
  1. _____ Mentally sluggish, reduced initiative
  2. _____ Easily fatigued, sleepy during the day
  3. _____ Sensitive to cold, poor circulation (cold hands and feet)
  4. _____ Constipation, chronic
  5. _____ Excessive hair loss and / or coarse hair
  6. _____ Morning headaches, wear off during the day
  7. _____ Loss of lateral 1/3 of eyebrow
  8. _____ Seasonal sadness

Section 12 MEN ONLY

  1. _____ Prostate problems
  2. _____ Urination difficult or dribbling
  3. _____ Difficult to start and stop urine stream
  4. _____ Pain or burning with urination
/
  1. _____ Waking to urinate at night
  2. _____ Interruption of stream during urination
  3. _____ Pain on inside of legs or heels
  4. _____ Feeling of incomplete bowel evacuation
  5. _____ Decreased sexual function

Section 13 WOMEN ONLY

  1. _____ Depression during periods
  2. _____ Mood swings associated with periods (PMS)
  3. _____ Crave chocolate around periods
  4. _____ Breast tenderness associated with cycle
  5. _____ Excessive menstrual flow
  6. _____ Scanty blood flow during periods
  7. _____ Occasional skipped periods
  8. _____ Variations in menstrual cycles
  9. _____ Endometriosis
  1. _____ Uterine fibroids
/
  1. _____ Breast fibroids, benign masses
  2. _____ Painful intercourse (dyspareunia)
  3. _____ Vaginal discharge
  4. _____ Vaginal dryness
  5. _____ Vaginal itchiness
  6. _____ Gain weight around hips, thighs and buttocks
  7. _____ Excess facial or body hair
  8. _____ Hot flashes
  9. _____ Night sweats (in menopausal females)
  10. _____ Thinning skin

Section 14

  1. _____ Aware of heavy and / or irregular breathing
  2. _____ Discomfort at high altitudes
  3. _____ "Air hunger" and / or yawn frequently
  4. _____ Compelled to open windows in a closed room
  5. _____ Shortness of breath with moderate exertion
/
  1. _____ Ankles swell, especially at end of day
  2. _____ Cough at night
  3. _____ Blush or face turns red for no reason
  4. _____ Dull pain or tightness in chest and / or radiate into right arm, worse with exertion
  5. _____ Muscle cramps with exertion

Section 15

  1. _____ Pain in mid back region
  2. _____ Dark circles under eyes and / or puffy eyes
  3. _____ History of kidney stones (1 = yes, 0 = no)
/
  1. _____ Cloudy, bloody or darkened urine
  2. _____ Urine has a strong odor

Section 16

  1. _____ Runny or drippy nose
  2. _____ Catch colds at the beginning of winter
  3. _____ Mucus producing cough
  4. _____ Frequent infections (ear, sinus, lung, skin, bladder,
    kidney, etc.)
  5. _____ Frequent colds or flu
  6. _____ Never get sick (3 = not in last 7 yrs., 2 = not in last 4 yrs.,
    1 = not in last 2 yrs.)
/
  1. _____ Acne (adult)
  2. _____ Itchy skin / dermatitis
  3. _____ Cysts, boils, rashes
  4. _____ History of Epstein Bar, Mono, Herpes, Shingles,
    Chronic Fatigue, Hepatitis or other chronic viral condition
    (1 = yes, 0 = no)

………………………………………………………………………………………………………………………………………………………………. Write down all the foods and drinks consumed over the next two days, starting today. Please add as much information as possible including quantities eaten, brand names, and whether the food is fresh or packaged, refined or natural.

Day 1Day 2__ Breakfast Breakfast

______

LunchLunch

______

DinnerDinner

______

Snacks/DrinksSnacks/Drinks

Are these two days representative of your usualWhich Nutritional Supplements do you take regularly?

Eating habits? If not, what is a more usual day?Please include brand names and quantity. (eg. 500mg)

Breakfast

______

Lunch

______

Dinner

______

Snacks/Drinks

Please return completed form to:

Athlone Nutrition Clinic

2 Garden Vale

Athlone

Westmeath

Or email to: before your appointment.

Ph: 090 64 70897 / 087 7927471

Get Healthy! Consultation Costs

  • 3 Step Nutritional Programme (for general improvement of physical and mental health): €150 (inc. pre-consultation questionnaire review, consultation and follow-up consultation with support in between).
  • 8 Week Health & Weight Management Programme (for chronic (long-term) health conditions and weight loss): €400 over 8 weekly sessions.

Directions for consultation – Athlone Nutrition Clinic, 2 Garden Vale, Athlone:

Coming from Dublin: Exit no. 10 off dual carriageway; turn left; then straight through roundabout; straight into town and through traffic lights at crossroad; turn left into car park and Athlone Nutrition Clinic is directly opposite the car park in no.2 Garden Vale; look for the red door.

Coming from Galway: Exit no. 10 off dual carriageway; turn right; then straight through roundabout; straight into town and through traffic lights at crossroad; turn left into car park and Athlone Nutrition Clinic is directly opposite the car park in no.2 Garden Vale; look for the red door.

Coming from Longford: Drive past the Colm Quinn garage on your right; straight through first roundabout; straight through second roundabout; straight into town and through traffic lights at crossroads; turn left into car park and Athlone Nutrition Clinic is directly opposite the car park in no.2 Garden Vale; look for the red door.

Coming from Roscommon: Turn right on to the dual carriageway at Ganly’s hardware store, heading towards Dublin; take exit 10; turn right; then straight through roundabout; straight into town and through traffic lights at crossroad; turn left into car park and Athlone Nutrition Clinic is directly opposite the car park in no.2 Garden Vale; look for the red door.

NB: Should you need to reschedule an appointment please do so min. 48 hours prior to appointment otherwise a 50% charge will incur.

Key: 0 (or leave blank) = No or Do not have symptom, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly)

1 = Yes or Minor or mild symptom (once a month or less)3 = Severe symptom, frequently occurs (daily)

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