Questionnaire Re-Evaluation

Measured NutritionÔ, LLC

Nutritional Evaluation Questionnaire

(For Re-Evaluation)

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

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?
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:
1.			Do you donate blood? If yes, when was the last time?
2.			How often do you usually donate blood?
3.			Have you traveled overseas in last 3 mos?
4.			Had surgery within the last 90 days?

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.	Have your headaches: SAME, INCREASED, DECREASED?
7.	How often do you get muscle cramps? Daily, Weekly, Monthly, Rarely, Year+ ago
8.	When was your last muscle cramp?
9.	Have your muscle cramps: SAME, INCREASED, DECREASED?
10.	What was your last Antioxidant (Carotenoid) Score with the Pharmanex BioPhotonic Scanner: Your Score: Date of Scan:
11.	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?
12.	If you had bone loss, what were your T-Scores:
13.	When was the last time you had your blood pressure checked?
14.	What was your blood pressure then? over
15.	How would you describe the health of your teeth and gums?
16.	How deep (in millimeters) are your deepest gum pockets?
17.	How many hours do you sleep per night on the average?
18.	How would you describe the quality of your sleep?
19.	On the average, how many times do you wake at night to urinate?
20.	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?
7.	Since your previous Nutrition Evaluation, has your pain been: SAME, INCREASED, DECREASED?

If you have Joint Pain, answer the following questions:

8.	Pain location(s):
9.	Pain level 1-10:
10.	Pain frequency: constant, daily, weekly, monthly, rarely
11.	Pain description:
12.	How long have you had the pain? Week, Month(s), Year(s)
13.	What do you do or take for the pain?
14.	Since your previous Nutrition Evaluation, has your pain been: SAME, INCREASED, DECREASED?

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)?

	Description	Y/N
1.	Have you traveled overseas in last 3 mos?
2.	Had surgery within the last 90 days?

Please check the following items to show what has changed since your previous evaluation.

The categories are: N/A=Didn't have or Not applicable, R=resolved (gone), B=still have but better, NC=No change/same, or W=gotten worse

	Item Description	N/A	Resolved	Better	No Change	Worse
1.	Bloating, gas, indigestion
2.	Bowel Movements 2 to 4 per day desirable
3.	Sleep
4.	Sweet and sugar cravings
5.	Cracking or splitting finger nails
6.	Cold hands or feet
7.	Bone Loss
8.	Experience depression, moodiness or irritability?
9.	Low Energy, Fatigue

Males Only:

	Item Description	N/A	Resolved	Better	No Change	Worse
1.	Pain/ burning upon urinating?
2.	Wake up to urinate at night?
3.	Ejaculation cause pain?
4.	Experience low sex drive?
5.	Have premature ejaculation?
6.	Difficulty attaining/maintaining an erection
7.

Females Only:

	Item Description	N/A	Resolved	Better	No Change	Worse
1.	Heavy menstrual bleeding?
2.	Vaginal itching or discharge?
3.	Vaginal dryness?
4.	Low or no desire for sex?
5.	Monthly cramps?
6.	Tender Breasts?
7.	Painful intercourse?
8.	Hot flashes?
9.	Menstrual cycle irregular?
10.

List any other issues that are not mentioned above:

1.
2.
3.
4.

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.	Improve energy level or reduce/eliminate 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
Swanson	Calcium, Albion 180 mg
Swanson	Chromium, Albion 200 mcg
Optimal Health Sys.	Chronic
Optimal Health Sys.	Complete Nutrition (scoop)
Solgar or Blue Bonnet	Copper, Chelated
Optimal Health Sys.	Defense
Optimal Health Sys.	Digestion Formula
Optimal Health Sys.	Fat/Sugar
Optimal Health Sys.	Female
Optimal Health Sys.	Flora Plus
Optimal Health Sys.	Fruit & Veggie Complete
Pharmanex	G3 Juice (oz)
Optimal Health Sys.	Greatest Vitamin
	Iodoral (Iodine)
Optimal Health Sys.	Iron
Optimal Health Sys.	Liver/Kidney
Swanson	Magnesium, Albion 100 mg
Optimal Health Sys.	Male
Swanson	Manganese, Albion Chelated 40 mg
Solgar	Molybdenum, Chelated
Udo’s Choice by Flora	Oil Blend (tablespoon)
Optimal Health Sys.	Opti-Force Total Antioxidant
Optimal Health Sys.	OptiKids Enzyme/Probiotic Chewables
Optimal Health Sys.	OptiKids Vitamin/Mineral Chewables
Optimal Health Sys.	Opti-Mass
Optimal Health Sys.	Opti-Trim
Optimal Health Sys.	OsteoPlus
Dr. Tony	Radiant Greens (tablespoon)
Dr. Tony	Ruby Reds (tablespoon)
Swanson	Selenium, Chelated
Optimal Health Sys.	Vitamin/Mineral/Antioxidant
Bob’s Red Mill	Wheat Germ, Raw (tablespoon)
Optimal Health Sys.	Whole B (teaspoon)
Optimal Health Sys.	Whole C (Chewable)
Swanson	Zinc, Albion Chelated

The End

Measured NutritionÔ, LLC

Nutritional Evaluation Questionnaire

Product Name

Comments

Product Name (alphabetical order)

Comments