Questionnaire

Measured NutritionÔ, LLC

Nutritional Evaluation Questionnaire

Date:

Name:

Email:

Address:

City:

State:

Zip:

Phone: ( )

Who referred you?

Age:

Male:

Female:

Height:

Weight:

Body Fat %:

Your Nutrition or Health Goal(s):

Chief Concern(s):

Surgeries and year(s) that you had them:

1.	When was your last doctor’s physical:
2.	When was your last doctor’s blood test (bring a copy):

Prescription Medications Usage or Over the Counter Medications: - Please check if you use any of the following:

1.	Antacids, Zantac, Pepcid AC, Rolaids, etc	10.	Aspirin/Acetaminophen
2.	Laxatives	11.	Cortisone/Anti-Inflammatories
3.	Ulcer Medications	12.	Cholesterol Lowering Medication
4.	Anti-diabetic/Insulin	13.	Heart Medications
5.	Relaxants/Sleeping Pills	14.	High Blood Pressure Medicine
6.	Thyroid	15.	Blood Thinners
7.	Chemotherapy	16.	Oral Contraceptives
8.	Radiation	17.	Hormones
9.	Antidepressants

18.	Antibiotic/Antifungal: Last time taken (Month-Year):
19.	Other medications not listed:
20.	List allergies to medications:
21.	List allergies to foods:
22.	List allergies to other things:

DIETARY HABITS:

Are you a vegetarian? Yes No
If yes, How long?	What percentage of your diet is RAW food? __________%

Describe the foods you normally eat:

Breakfast:

Lunch:

Dinner:

Snacks:

How times per week do you eat:

Cheese	Fish	Other Whole Grains	Soda
Red Meat	Eggs	Vegetables	Pizza
Chicken/Turkey	Cereal (Whole grain)	Fruits	Ice Cream
Beans/Legumes	Brown Rice	Nuts/Seeds	Coffee
			Fast Food

Check if you eat or drink:

1.	Candy	3.	Distilled Water
2.	Tap Water	4.	MRET Water
3.	Bottled Spring/Filtered Water	5.	Penta Water
4.	Reverse Osmosis Water	6.	Soft Water (Sodium or Potassium)

Please check: YES, Sometimes, Rarely or NO How often do you consume:

	Yes	Some-times	Rarely	No	Description
1.					Soda or carbonated beverages of any kind including carbonated water?
2.					White flour products?
3.					Fried foods?
4.					Fifty percent of your food in its raw form?
5.					Sugars other than fructose, sucanat, stevia, or raw organic honey?
6.					Artificial sweeteners?
7.					Red meat or pork?
8.					Tap water?
9.					Artificial colors, flavoring, MSG or preservatives (BHT, etc.)
10.					Hydrogenated or partially hydrogenated oils?
11.					Any tobacco products? How many years you used _____?
12.					Alcoholic beverages?
13.					Eight to ten glasses of water daily?
14.					At least six servings of whole grains daily? (Serving size: 1 piece of bread or ¾ c. oatmeal)
15.					At least three servings of fresh fruit daily? (Serving size is ½ c. chopped)
16.					At least three servings of vegetables daily? (Serving size is ½ c. chopped)
17.					Two to three servings of protein daily (eggs, raw nuts, legumes, beans, lean meats)?
18.					Two servings daily of dairy (low-fat milk, cottage cheese, yogurt, etc.)?
19.					One Tbsp. of flax seeds daily?
20.					Oils in the form of extra virgin olive oil and safflower or canola oil daily?
21.					Real butter as opposed to margarine?
22.					Mainly grains, some fruits and vegetables, a small amount of dairy and protein and sparingly fats, oils and sweets daily (according to the Eating Right Pyramid)?

How times per week on average do you Exercise:

Aerobic class	Hike	Pilates	Lift Weights
Walk	Bike/Cycle	Yoga
Jog or Run	Swim	Other Aerobic

	Yes	No	Do you have a fitness goal?
1.			If so, what is it?

Please check: YES or NO

	Yes	No	Question:
2.			Do you donate blood? If yes, when was the last time?
3.			How often do you usually donate blood?

Please check: YES or NO

Yes

Question:

While standing and leaning forward with your legs straight, can you?

Touch your finger tips to the floor?

Touch the palm of your hands FLAT to the floor?

Please answer the following questions:

1.	How often do you have a bowel movement per day or week?
2.	Have you ever had a Colonic (intestine flush)? Yes or No If so, when was the last time?
3.	When was the last time you had parasites or had been treated for parasites?
4.	How often do you get headaches? Daily, Weekly, Monthly, Rarely, Year+ ago
5.	When was your last headache?
6.	How often do you get muscle cramps? Daily, Weekly, Monthly, Rarely, Year+ ago
7.	When was your last muscle cramp?
8.	What was your last Antioxidant (Carotenoid) Score with the Pharmanex BioPhotonic Scanner: Your Score: Date of Scan:
9.	Have you had a bone density test to determine if you have bone loss? Yes No If yes, did it indicate bone loss? No bone loss, Osteopenia or Osteoporosis?
10.	If you had bone loss, what were your T-Scores:
11.	When was the last time you had your blood pressure checked?
12.	What was your blood pressure then? over
13.	How would you describe the health of your teeth and gums?
14.	How deep (in millimeters) are your deepest gum pockets?
15.	How many hours do you sleep per night on the average?
16.	How would you describe the quality of your sleep?
17.	On the average, how many times do you wake at night to urinate?
18.	On the average, how many times do you wake at night for other reasons?

If you have Muscle or Tissue Pain, answer the following questions:

1.	Pain location(s):
2.	Pain level 1-10:
3.	Pain frequency: constant, daily, weekly, monthly, rarely
4.	Pain description:
5.	How long have you had the pain? Week, Month(s), Year(s)
6.	What do you do or take for the pain?

If you have Joint Pain, answer the following questions:

7.	Pain location(s):
8.	Pain level 1-10:
9.	Pain frequency: constant, daily, weekly, monthly, rarely
10.	Pain description:
11.	How long have you had the pain? Week, Month(s), Year(s)
12.	What do you do or take for the pain?

Hair Appearance - Check best description:

1.	Full head of hair?			3.	Almost have a bald spot?
2.	Hair is thinning some?			4.	Have a bald spot?

Hair Products:

1.	What brand(s) of hair shampoo and conditioners do you use?
2.	If you use hair color, when was the last coloring?
3.	What brand of color do you use?
4.	What is the name of color(s)?

INSTRUCTIONS: Enter the number which best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.

0 = Never have 1 = Occasionally Have 2 = Frequently have 3 = Constantly have

Section 1 – Digestion Section 4 - Liver/Kidney

1.	Do you use antacids?	37.	Are the whites of your eyes yellowish?
2.	Does food pass through undigested?	38.	Do you experience back pain over kidneys?
3.	Do you experience bloating?	39.	Do you have strong-smelling urine?
4.	Fullness for extended time after meals?	40.	Do you experience distress from eating fatty foods?
5.	Excessive appetite?	41.	Do you experience an unpleasant taste In your mouth?
6.	Sleepy or low energy after eating?	42.	Do you have high cholesterol (above 200)? Y N
7.	Do you eat a lot of processed foods?	43.	Do you have pain in the upper quadrant of your stomach?
8.	Do you experience indigestion?	44.	Do you have dry skin?
9.	Uncomfortable/adverse reactions to food?	45.	Persistent burning in your stomach?
10.	Is your bowel function irregular (less than twice/day)?	46.	Flatulence or gas after meals?
11.	Do roughage and fiber cause constipation?	47.	Do you eat red meats and/or high fat diet?
12.	Do you use enemas?
13.	Do you use laxatives?

Section 2 – Vitamin/Mineral/Antioxidant Section 5 – Iron

14.	Do you have varicose veins?	48.	Do you have anemia?
15.	Do you bruise easily?	49.	Do you eat a low fiber diet?
16.	Do you have poor stamina?	50.	Is your skin clammy feeling?
17.	Do you have trouble sleeping?	51.	Do you have frequent headaches?
18.	Do you have persistent leg cramps?	52.	Is your menstrual flow excessive?
19.	Is your diet unbalanced?	53.	Are you under 18 years old?
20.	Are you nervous/ have poor concentration?	54.	Are you pregnant?
21.	Do you have age spots?	55.	Are you an endurance athlete?
22.	Is your vision failing rapidly?	56.	Do you have low energy, fatigue?
23.	Do you smoke or are exposed to smoke?	57.	Do you eat a low carbohydrate diet?
24.	Do you drink 5+ cups of coffee/cola daily?	58.	Do you have persistent shortness of breath?
25.		59.	Do you have ridges in your fingernails?

Section 3 – Fat/Sugar Section 6 – Flora Plus

26.	Do you crave sweets and sugars?	60.	Do you have persistent bad breath?
27.	Do you feel weak/faint between meals?	61.	Do you consume dairy products, meat and/orpoultry?
28.	Do you have unstable blood sugar levels?	62.	Are you taking or have taken antibiotics within the last 90 days? Yes No
29.	Is your cholesterol over 200?	63.	Do you have a history of food poisoning?
30.	Is your triglyceride level over 175?	64.	Have you traveled overseas in last 3 mos?
31.	Are you unable to lose or gain weight?	65.	Do you have persistent flatulence or gas?
32.	Do you crave fatty foods?	66.	Do you consume alcohol or carbonated beverages/soda?
33.	Do you have dry skin and hair?	67.	Do you get sick often?
34.	Excessive thirst?	68.	Do you get cold sores frequently?
35.	Pain under your right rib cage? (0)NO (2)YES	69.	Had surgery within the last 90 days?
36.	Family history of diabetes? (0)NO (5)YES	70.	Do you have persistent diarrhea?

INSTRUCTIONS: Enter the number which best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.

0 = Never have 1 = Occasionally Have 2 = Frequently have 3 = Constantly have

Section 7 – Acute Section 10 – Osteo Plus

71.	Have you been on a high-protein diet or eat more than 6 oz. of protein a day?	103.	Do you have osteopenia?
72.	Do you have painful joints in your hands?	104.	Do you have osteoporosis?
73.	Do you have painful joints in your legs?	105.	Do you eat dairy products? (2)NO (0)YES (1)SOMETIMES
74.	Do you have painful joints in your feet?	106.	Do you eat leafy green vegetables, spinach and broccoli? (1)SOMETIMES (2)NO (0)YES
75.	Do you have disc problems?	107.	Do you drink coffee, tea or cola drinks?
76.	Are your injuries slow to heal?	108.	Do you smoke?
77.	Is it hard to strengthen your muscles?	109.	Do you drink alcohol?
78.	Do you have frequent fevers or infections?	110.	Do you have family history of osteoporosis?
79.	Do you have muscle pain?	111.	Are you over 50? (0)NO (2)YES
80.	Do you have muscle cramps?	112.	Are you post menopausal?
81.	Have you been injured within last 3 mos? (0)NO (2)YES	113.	Have you had hormonal problems of any kind?
82.	Do you have poor circulation or experience cold hands or cold feet?	114.	Do you have a small frame or low weight? (0)NO (2)YES

Section 8 – Chronic Section 11 – Male Only

83.	Do you have chronic back pain?	115.	Does your bladder always feel full?
84.	Do you have overflexibility in your joints (double-jointed)? (0)NO (1)YES	116.	Do you have pain/ burning upon urinating?
85.	Do you have bursitis?	117.	Do you wake up to urinate at night?
86.	Do you have arthritis?	118.	Does ejaculation cause pain?
87.	Do you have tendonitis?	119.	Do you experience low sex drive?
88.	History of joint injury? Y N	120.	Do you have premature ejaculation?
89.	Do you have pain in your fingers or wrists?	121.	Do you have difficulty attaining and/or maintaining an erection?
90.	Do your bones ache or feel painful/sore?	122.	Are you infertile? (0)NO (3)YES
91.	Do you have swollen joints?
92.	Chronic pain in:

Section 9 – Oxy Pure Section 12 – Females Only

93.	Do you have candida?	123.	Are you post menopausal? (0)NO (7)YES
94.	Do you get fungal infections?	124.	Do you experience depression, moodiness or irritability?
95.	Do you get yeast infections?	125.	Do you have heavy menstrual bleeding?
96.	Do you experience persistent illnesses?	126.	Do you have vaginal itching or discharge?
97.	Are you unable to get good results from antibiotics?	127.	Do you have vaginal dryness?
98.	Do you seem to get sick easily?	128.	Low or no desire for sex?
99.	Do you have food allergies?	129.	Do you have monthly cramps?
100.	Do you have pain in any of your joints?	130.	Do you have pale skin?
101.	Do you experience anal itching?	131.	Do you have tender breasts?
102.	Do you have athletes’ foot?	132.	Painful intercourse?
		133.	Do you have anemia?
		134.	Do you have persistent low energy?
		135.	Do you have cracking around lips or a white tongue?
		136.	Do you experience hot flashes
		137.	Is you menstrual cycle irregular?

List any other issues that are not mentioned above:

1.
2.

Client Priorities

Circle Yes for those items that are important to you. Feel free to add items to the list. Then rank them from 1 to 10+ by writing the priority number. Use priority 1 for the most important item then use priority 2 for the second item, then use 3, 4. 5, 6, etc. for next important items.

No	Description	Important Yes/No	Priority 1, 2, etc	Comments
1.	Improve athletic performance	Yes No
2.	Consistent bowel movements 2 or 3 per day	Yes No
3.	Reduce or eliminate the need for antacids like Pepsid, Tums, Rolaids, etc.	Yes No
4.	Improve bone density - Reduce or eliminate Osteopenia or Osteoporosis	Yes No
5.	Reduce or eliminate headaches	Yes No
6.	Reduce or eliminate sugar cravings	Yes No
7.	Reduce or eliminate fatty food cravings	Yes No
8.	Reduce or eliminate infections	Yes No
9.	Reduce or eliminate flu or colds	Yes No
10.	Reduce or eliminate food allergies	Yes No
11.	Reduce or eliminate bowel gas	Yes No
12.	Reduce or eliminate sleep medications	Yes No
13.	Improve sleep quality	Yes No
14.	Males: Reduce or eliminate prostate enlargement	Yes No
15.	Increase muscle mass	Yes No
16.	Reduce body fat	Yes No
17.	Reduce or eliminate joint pain	Yes No
18.	Reduce or eliminate muscle or tissue pain	Yes No
19.	Improve flexibility to touch hand palms to the floor	Yes No
20.	Reduce or eliminate muscle cramps	Yes No
21.	Reduce or eliminate waking to urinate at night	Yes No
22.	Increase energy or reduce fatigue	Yes No
23.		Yes No
24.		Yes No
25.		Yes No
26.		Yes No
27.		Yes No
28.		Yes No
29.		Yes No
30.		Yes No
31.		Yes No
32.		Yes No
33.		Yes No

If you have taken supplement products during the past 2 to 4 months, please list them below:

· Brand

· Product Name

· Quantity normally taken

If you are taking products from Optimal Health Systems, go to the next page where the products are listed for your convenience.

Company or Brand	Product Name	Quantity taken Daily	Comments

List the supplement products and quantity taken daily. Add to the list any supplement products not shown. These may be other brands of products.

Company or Brand	Product Name (alphabetical order)	Quantity taken Daily	Comments
Optimal Health Sys.	AdrenaBoost
Optimal Health Sys.	Acute
Nature’s Way	Boron
Optimal Health Sys.	Calcium 80 mg
Swanson	Calcium, Albion 180 mg
Swanson	Chromium, Albion 200 mcg

Measured NutritionÔ, LLC

Nutritional Evaluation Questionnaire

Product Name

Comments

Product Name (alphabetical order)

Comments