Pembroke Holistic Center

Nutritional Assessment Questionnaire

Please be aware that this questionnaire is extensive and will take some time to complete - There is no "save" feature.  If you exit your browser and return to the form, it will have been reset and you will need to start again.

For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).   

Name    
Phone
        e-mail
Address       City 
State
      Zip  
Birthday:    Month    Day    Year  
SEX:   Male        Female

Name of Your Primary Care Physician (leave blank if you do not have one)

Occupation:

 Please list your five major health concerns in order of importance
1. 
2. 
    
3.     
4.     
5.    

Please List all Allergies



List all medications and supplements you are currently taking.  Please list dosage and frequency of each.

Medications:
 


Supplements:

 


INSTRUCTIONS: Read the following questions and click the number that applies:

Add values for each answer and input into "Total Section"  (for example 0+3+2+1+0+2+3+2+1+3+2+1+3+2+1+0+2+3+2=33)

Please add your scores per section and enter into the "TOTAL SECTION" box This Nutritional Assessment Questionnaire has 321 Questions, Please be aware that it will take some time to fill this survey out in it's entirety - THERE IS NO SAVE FEATURE SO DO NOT EXIT FORM WHILE COMPLETING OR YOU WILL LOSE ALL YOUR ENTRIES.

Revise and click on the "Submit Button" below when finished

0=Do not consume or use, 1=Consume or use 2 to 3 times monthly, 2=2, 3=Consume or use daily
           
I 0 1 2 3   SECTION ONE
1

Alcohol

2 Artificial Sweetners
3 Candy, desserts, refined sugar
4 Carbonated beverages
5 Chewing tobacco
6 Cigarettes
7 Cigars/pipes
8 Caffeinated beverages
9 Fast foods
10 Fried Foods
11 Luncheon/Cold cut meats
12 Margarine
13 Milk products
14     Radiation exposure ( 0=no, 1=yes )
15 Refined flour/baked goods
16 Vitamins and minerals
17 Water, distilled
18 Water, tap
19 Water, well
20 Diet often for weight control
     TOTAL SECTION I
   
II 0 1 2 3   SECTION TWO
21 Exercise per week ( 0=two or more times a week,  1=once a week,  2=one or two times a month,  3=never, less than once a month)
22 Changed jobs (0=over 12 months ago,  1=within last 12 months,  2=within last 6 months,  3=within last 2 months
23 Divorced (0=never, over 2 years ago,  1=within last 2 years,  2=within last year,  3=within last 6 months
24 Work over 60 hours/week (0=never,  1=occasionally,  2=usually,  3=always
     TOTAL SECTION II   
   
III NO YES      SECTION THREE- Indicate any medictions you are currently taking or have taken in the last month (0=no, 1=yes)
25 Antacids
26     Antianxiety medications
27     Antibiotics
28     Anticonvulsants
29     Antidepressants
30     Antifungals
31     Aspirin/ibuprofen
32     Asthma inhalers
33     Beta blockers
34     Birth control pills/implant contraceptives
35     Chemotherapy
36     Cholesterol lowering medicaitons
37     Cortisone/steroids
38     Diabetic medications/insulin
39     Diuretics
40 Estrogen or progesterone (pharmaceutical, prescription)
41     Estrogen or progesterone (natural)
42     Heart medications
43     High blood pressure medications
44     Laxatives
45     Recreational drugs
46     Relaxants/Sleeping pills
47     Testosterone (natural or prescription)
48     Thyroid medication
49     Acetaminophen (Tylenol)
50     Ulcer medications
51     Sildenafil citrate (Viagra or like)
     TOTAL SECTION III   
       
IV 0 1 2 3 SECTION FOUR
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
52 Belching or gas within one hour after eating
53 Heartburn or acid reflux
54 Bloating within one hour after eating
55     Vegan diet (no dairy, meat, fish or eggs)  (0=No,  1=Yes
56 Bad breath (halitosis)
57 Loss of taste for meat
58 Sweat has a strong odor
59 Stomach upset by taking vitamins
60 Sense of excess fullness after meals
61 Feel like skipping breakfast
62 Feel better if you don't eat
63 Sleepy after meals
64 Fingernails chip, peel or break easily
65 Anemia unresponsive to iron
66

Stomach pains or cramps

67 Diarrhea, chronic
68 Diarrhea shortly after meals
60  Black or tarry colored stools
70 Undigested food in stool
     TOTAL SECTION IV   
           
V 0 1 2 3 SECTION FIVE  
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
71 Pain between shoulderblades
72 Stomach upset by greasy foods
73 Greasy or shiny stools
74 Nausea
75 Sea, car, airplane or motion sickness
76     History of morning sickness (0=No,  1=Yes)
77 Light or clay colored stools
78 Dry skin, itchy feet or skin peels on feet
79 Headache over eyes
80 Gallbladder attacks (0=Never, 1=years ago,2=within last year,  3=within past 3 months)
81     Gallbladder removed (0=No,  1=Yes)
82 Bitter taste in mouth, especiall after meals
83 Become sick if you were to drink wine (0=No,  1=Yes)
84     Easily hung over if you were to drink wine (0=No,  1=Yes)
85 Alcohol per week (0=<3, 1=<7, 2=<14, 3=>14)
86     Recovering alcoholic (0=No,  1=Yes)
87 History of drug or alcohol abuse (0=No, 1=Yes)
88     History of hepatitis (0=No,  1=Yes
89     Long term use of prescription drugs (0=No,  1=Yes)
90     Long term use of recreational drugs (0=No,  1=Yes)
91 Sensitive to chemicals (perfume, cleaning agents, etc.)
92 Sensitive to tobacco smoke
93 Exposure to diesel fumes
94 Pain under right side of rib cage
95 Hemorrhoids or varicose veins
96 NutraSweet (aspartame) consumption
97 Sensitive to NutraSweet (aspartame)
98 Chronic fatigue or Fibromyalgia
     TOTAL SECTION V   
           
VI 0 1 2 3 SECTION SIX 
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
99 Food allergies
100 Abdominal bloating 1 to 2 hours after eating
101     Specific foods make you tired or bloated (0=No, 1=Yes)
102 Pulse speeds after eating
103

Airborne allergies

104 Experience hives
105 Sinus congestion, stuffy head
106 Crave bread, noodles or pasta
107 Alternating constipation and diarrhea
108     Crohn's disease (0=No, 1=Yes)
109 Wheat or grain sensitivity
110 Dairy sensitivity
111     Are there foods you could not give up? (0=No, 1=Yes)
112 Asthma, sinus infections, stuffy nose
113 Bizarre vivid dreams, nightmares
114 Use over-the-counter pain medications
115 Feel spacey or unreal
     TOTAL SECTION VI   
   
VII 0 1 2 3 SECTION SEVEN 
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
116 Anus itches
117 Coated tongue
118 Feel worse in moldy or musty place
119 Taken antibiotics for a total accujmulated time of (0=Never, 1=less than 1 month, 2=less than 3 months,3=more than 3 months
120 Fungus or yeast infections
121 Ring worm, jock itch, athletes foot, nail fungus
122 Yeast symptoms increase with sugar, starch or alcohol
123 Stools hard or difficult to pass
124     History of parasites (0=No, 1=Yes)
125 Less than one bowel movement per day
126 Stools have corners or edges, are flat or ribbed shaped
127 Stools are not well formed (loose)
128 Irritable bowel or mucus colitis
129 Blood in stool
130 Mucus in stool
131 Excessive foul smelling lower bowel gas
132 Bad breath or strong body odors
133 Painful to press along outer sides of thighs (iliotibial band)
134 Cramping in lower abdominal region
135 Dark circles under eyes
     TOTAL SECTION VII   
           
VIII 0 1 2 3 SECTION EIGHT  
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
136     History of carpal tunnel syndrome (0=No,  1=Yes)
137     History of lower right abdominal pains or ileocecal valve problems (0=No,  1=Yes)
138     History of stress fracture (0=No,  1=Yes)
139 Bone loss (reduced density on bone scan)
140     Are you shorter than you used to be? (0=No, 1=Yes)
141 Calf, foot or toe cramps at rest
142 Cold sores, fever blisters or herpes lesions
143 Frequent fevers
144 Frequent skin rashes and/or hives
145     Herniated disc (0=No,  1=Yes)
146 Excessively flexible joints "double jointed"
147 Joints pop or click
148 Pain or swelling in joints
149 Bursitis or tendonitis
150     History of bone spurs (0=No,  1=Yes)
151 Morning stiffness
152 Nausea with vomiting
153 Crave chocolate
154 Feet have a strong odor
155 History of anemia
156 Whites of eyes (sclera) blue tinted
157 Hoarseness
158 Difficulty swallowing
159 Lump in throat
160 Dry mouth, eyes and/or nose
161 Gag easily
162 White spots on fingernails
163 Cuts heal slowly and/or scar easily
164 Decreased sense of taste or smell
     TOTAL SECTION VIII   
           
IX 0 1 2 3 SECTION NINE  
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
165     Experiences pain relief with aspirin (0=No, 1=Yes)
166 Crave fatty or greasy foods
167 Low or reduced fat diet (0=Never, 1=years ago,2=within past year, 3=currently)
168 Tension headaches at base of skull
169 Headaches when out in the hot sun
170 Sunburn easily or suffer sun poisoning
171 Muscles easily fatigued
172 Dry flaky skin or dandruff
     TOTAL SECTION IX   
           
X 0 1 2 3 SECTION TEN  
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
173 Awaken a few hours after falling asleep, hard to get back to sleep
174 Crave sweets
175 Binge or uncontrolled eating
176 Excessive appetite
177 Crave coffee or sugar in the afternoon
178 Sleepy in afternoon
179 Fatigue that is relieved by eating
180 Headache if meals are skipped or delayed
181 Irritable before meals
182 Shaky if meals delayed
183 Family members with diabetes (0=None,1=1 or 2, 2=3 or 4, 3=more than 4)
184 Frequent thirst
185 Frequent urination
     TOTAL SECTION X   
           
XI 0 1 2 3 SECTION ELEVEN 
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
186 Muscles become easily fatigued
187 Feel exhausted or sore after moderate exercise
188 Vulnerable to insect bites
189 Loss of muscle tone, heaviness in arms/legs
190 Enlarged heart or congestive heart failure
191     Pulse below 65 per minute (0=No,  1=Yes)
192 Ringing in the ears (tinnitus)
193 Numbness, tingling or itching in hands and feet
194 Depressed
195 Fear of impending doom
196 Worrier, apprehensive, anxious
197 Nervous or agitated
198 Feelings of insecurity
199 Heart races
200 Can hear heart beat on pillow at night
201 Whole body or limb jerk as falling asleep
202 Night sweats
203 Restless leg syndrome
204 Cracks at corner of mouth (Cheilosis)
205 Fragile skin, easily chaffed, as in shaving
206 Polyps or warts
207 MSG sensitivity
208 Wake up without remembering dreams
209 Small bumps on back of arms
210 Strong light at night irritates eyes
211 Nose bleeds and/or tend to bruise easily
212 Bleeding gums especially when brushing teeth
     TOTAL SECTION XI   
           
XII 0 1 2 3 SECTION TWELVE
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
213 Tend to be a night person
214 Difficulty falling asleep
215 Slow starter in the morning
216 Tend to be keyed up, trouble calming down
217 Blood pressure above 120/80
218 Headaches after exercising
219 Feeling wired up or jittery after drinking coffee
220 Clench or grind teeth
221 Calm on the outside, troubled on the inside
222 Chronic low back pain, worse with fatigue
223 Become dizzy when standing up suddenly
224 Difficulty maintaining manipulative correction
225 Pain after manipulative correction
226 Arthritic tendencies
227 Crave salty foods
228 Salt foods before tasting
229 Perspires easily
230 Chronic fatigue, or get drowsy often
231 Afternoon yawning
232 Afternoon headaches
233 Asthma, wheezing or difficulty breathing
234 Pain on the medial or inner side of the knee
235 Tendency to sprain ankles or "shin splints"
236 Tendency to need sunglasses
237 Allergies and/or hives
238 Weakness, dizziness
     TOTAL SECTION XII   
           
XIII 0 1 2 3 SECTION THIRTEEN
0=No, symptom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
239     Height over 6'6" (0=No, 1=Yes)
240     Early sexual development (before age 10) (0=No, 1=Yes)
241 Increased libido
242 Splitting type headache
243 Memory failing
244     Tolerate sugar, feel fine when eating sugar (0=No, 1=Yes)
245     Height under 4'10" (0=No, 1=Yes)
246 Decreased libido
247 Excessive thirst
248 Weight gain around hips or waist
249     Menstrual disorders
250     Delayed sexual development (after age 13) (0=No, 1=Yes)
251 Tendency toward ulcers or colitis
     TOTAL SECTION XIII   
           
XIV 0 1 2 3 SECTION FOURTEEN
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
252 Sensitive/allergic to iodine
253 Difficulty gaining weight, even with large appetite
254 Nervous, emotional, can't work under pressure
255 Inward trembling
256 Flush easily
257 Fast pulse at rest
258 Intolerance to high temperatures
259 Difficulty losing weight
260 Mentally sluggish, reduced initiative
261 Easily fatigued, sleepy during the day
262 Sensitive to cold, poor circulation (cold hands and feet)
263 Constipation, chronic
264 Excessive hair loss and/or coarse hair
265 Morning headaches, wear off during the day
266 Loss of lateral 1/3 of eyebrow
267 Seasonal sadness
     TOTAL SECTION XIV   
           
XV 0 1 2 3 SECTION FIFTEEN - MEN ONLY
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
268 Prostate problems
269 Difficulty with urination, dribbling
270 Difficult to start and stop urine stream
271 Pain or burning with urination
272 Waking to urinate at night
273 Interruption of stream during urination
274 Pain on inside of legs or heels
275 Feeling of incomplete bowel evacuation
276 Decreased sexual function
     TOTAL SECTION XV   
           
XVI 0 1 2 3 SECTION SIXTEEN - WOMEN ONLY
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
277 Depression during periods
278 Mood swings associated with period (PMS)
279 Crave chocolate around periods
280 Breast tenderness associated with cycle
281 Excessive menstrual flow
282 Scanty blood flow during periods
283 Occasional skipped periods
284 Variations in menstrual cycles
285 Endometriosis
286 Uterine fibroids
287 Breast fibroids, benign masses
288 Painful intercourse (dysparenia)
289 Vaginal discharge
290 Vaginal dryness
291 Vaginal itchiness
292 Gain weight around hips, thighs and buttocks
293 Excess facial or body hair
294 Hot flashes
295 Night sweats (in menopausal females)
296 Thinning skin
     TOTAL SECTION XVI   
           
XVII 0 1 2 3 SECTION SEVENTEEN
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
297 Aware of heavy or irregular breathing
298 Discomfort at high altitutdes
299 "Air hunger" or sigh frequently
300 Compelled to open windows in a closed room
301 Shortness of breath with moderate exertion
302 Ankles swell, especially at end of day
303 Cough at night
304 Blush or face turns red for no reason
305 Dull pain or tightness in chest and/or radiate into right arm, worse with exertion
306 Muscle cramps with exertion
     TOTAL SECTION XVII   
           
XVIII 0 1 2 3 SECTION EIGHTEEN
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
307 Pain in mid-back region
308 Puffy around the eyes, dark circles under eyes
309     History of kidney stones (0=No, 1=Yes)
310 Cloudy, bloody or darkened urine
311 Urine has a strong odor
     TOTAL SECTION XVIII   
           
XIX 0 1 2 3 SECTION NINETEEN
0=No, symtom does not occur,  1=Yes, minor or mild symptom, rarely occurs (monthly),  2=Moderate symptom, occurs occasionally (weekly),  3=Severe symptom, occurs frequently (daily)
           
312 Runny or drippy nose
313 Catch colds at the beginning of winter
314 Mucus producing cough
315 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 a year)
316 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 a year)
317 Never get sick (0=sick only 1 or 2 times in the last 2 years, 1=not sick in last 2 years, 2=not sick in last 4 years, 3=not sick in last 7 years)
318 Acne (adult)
319 Itchy skin (dermatitis)
320 Cysts, boils, rashes
321 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
     TOTAL SECTION XIX   
           
          Notes: