Medical Questionnaire – Nutritional Screening Last Name(Required) First Name(Required) Date of Birth(Required) DD dash MM dash YYYY Check each item that applies to you most of the time.Screening for Essential Fatty Acid Deficiency I have soft, cracked or brittle nails. I have dry, itchy, flaky or flaky skin. I have hard earwax. I have chicken skin (small bumps on the back of my arms or on my trunk). I have dandruff. I feel pain or stiffness in my joints. I’m thirsty most of the time. I am constipated (I have less than 2 bowel movements a day). I have clear, hard or smelly stools. I’m in a bad mood, have trouble concentrating, and/or have memory loss. I have high blood pressure. I have fibrocystic breasts. I suffer from premenstrual syndrome. I have a personal or family history of LDL hypercholesterolemia, HDL hypercholesterolemia, and hypertriglyceridemia. I am of North Atlantic genetic descent: Irish, Scottish, Welsh, Scandinavian or coastal Amerindian. Vitamin D Deficiency Screening I have a family history of seasonal affective disorder (SAD) or winter depression. I have experienced a loss of mental acuity or memory. I have sore or weak muscles. I have sensitive bones (press down on your shin to see if it hurts). I work indoors. I avoid the sun. I wear sunscreen most of the time. I live North from Florida. I don’t eat small, oily fish like mackerel, herring, or sardines (the main source of dietary vitamin D). I have a personal and family history of osteoporosis. I broke more than two bones or had a hip fracture. I have a family history of autoimmune diseases (such as multiple sclerosis). I suffer from osteoarthritis. I have frequent infections. I have a personal or family history of prostate cancer. I have dark skin (any race other than Caucasian). I am 60 years of age or older. Magnesium Deficiency Screening I’m in a bad mood. I feel irritable. I have a hard time concentrating. I have a personal or family history of autism. I have trouble falling asleep and/or staying asleep. I have muscle twitching. I suffer from premenstrual syndrome. I have cramps in my legs or hands. I suffer from restless legs syndrome. I have heartbeats, rhythm jumps, or palpitations. I often have headaches or migraines. I have trouble swallowing. I suffer from acid reflux. I am sensitive to loud noises. I feel tired. I have a personal or family history of asthma. I suffer from constipation (less than 2 bowel movements a day). I have an excess of stress. I have kidney stones. I have a personal or family history of heart disease or heart failure. I have a personal or family history of mitral valve prolapse. I have a personal or family history of diabetes. I don’t eat much kelp, bran or wheat germ, almonds, cashews, buckwheat, or dark green leafy vegetables. Zinc Deficiency Screening I have questionable taste. My sense of smell is impaired. I have fragile nails (thin, brittle, flaking). I have white spots on my nails. I often get colds or respiratory infections. I have diarrhea. I have eczema or other rashes. I have acne. My wounds don’t heal well. I have allergies. I’m losing my hair. I have dandruff. I have a family history of erectile dysfunction. I have an enlarged or inflamed prostate. I have a personal or family history of inflammatory bowel disease (ulcerative colitis, Crohn’s disease). I have a personal or family history of rheumatoid arthritis. I use hard water (which depletes the zinc). I consume more than 3 alcoholic beverages per week. I sweat excessively. I have a personal or family history of kidney or liver disease. I am over 65 years old. I use diuretics (medication that makes you urinate more). I eat little dulse (seaweed), fresh ginger root, egg yolk, fish, kelp, lamb, legumes, and pumpkin seeds. Methylation deficiency (potential deficiencies of B12, folate, B6) I eat animal proteins (meat of any kind, dairy, cheese, eggs) more than 5 times a week. I eat more than 1-2 foods per week that contain hydrogenated fats (margarine, shortening, processed or packaged foods). I consume animal protein servings greater than 4-6 ounces (the size of the palm of my hand) per meal. I eat less than a cup of dark green leafy vegetables a day. I eat less than 5-9 servings (1/2 cup = 1 serving) of fruits and vegetables per day. I drink more than 3 alcoholic beverages a week. I’m in a bad mood. I have a history of heart attack or other heart disease. I have a history of stroke. I have a history of cancer (especially colon, cervical and breast cancer). I have a history of abnormal Pap testing (cervical dysplasia). I have a history of birth defects in my offspring (neural tube defects or Down syndrome). I have a history of dementia. I have a loss of balance or feeling in my feet. I have a history of multiple sclerosis or other diseases that cause nerve damage. I have a history of carpal tunnel syndrome. I don’t take a multivitamin. I am over 65 years old. CAPTCHA
