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Nutrient Survey Health Questionnaire Form

INSTRUCTIONS: Please read the questions below and put a check in front of the questions which most accurately describe you and the symptoms you normally experience. Many of the questions will seem similar to you and are included to assure accuracy of test results.

Your answers are completely anonymous and the results will be shown to you without any personal information entered.

1. Do you have trouble judging distances while driving at night?
2. Do you have little bumps on your upper arm?
3. Do your eyes ever burn or itch?
4. Do you have poor immunities, getting sick frequently?
5. Is acne a problem for you?
6. Have you gotten a new wart(s) in the last six months?
7. Do you pass blood clots or hemorrhage during your menstrual period?
8. Do you have a general lack of energy?
9. Do your lips crack, chap, or feel dry frequently?
10. Do you feel tired when you get up in the morning?
11. Do your feet smell when you take off your socks?
12. Do you eat chocolate or drink more than 2 cups of coffee daily?
13. Females - Do you currently use synthetic estrogen or birth control pills?
14. Do you have pucker marks on your upper lip?
15. Do you bruise easily?
16. Do you ever get nosebleeds?
17. Do you smoke cigarettes?
18. Do you have any bruises right now?
19. Do you ever get leg cramps, "Charlie horses" or menstrual cramps?
20. Do you have muscle spasms?
21. Do you feel nervous or irritable at times?
22. Do you ever break bones?
23. Do you have difficulty sleeping well?
24. Do you ever experience shooting pains in your left arm?
25. Have you ever had a heart attack or a stroke?
26. Do your hands or feet fall asleep easily?
27. Do you ever have blood clots or varicose veins?
28. Females - Are you infertile, on birth control pills or menopausal?
29. Males - Have you lost your sex drive?
30. Do you have high cholesterol, triglycerides, or blood pressure?
31. Do you have problems with water retention?
32. Have you ever had kidney stones?
33. Females - Is Premenstrual Tension a problem for you?
34. Do you experience motion sickness easily?
35. Do you have a high cholesterol level?
36. Do you generally have a poor appetite?
37. Are you anemic?
38. Are you a vegetarian, seldom eating flesh foods?
39. Do you feel fatigued or depressed frequently?
40. Do you have poor digestion?
41. Do you feel as if your concentration and memory are failing?
42. Do you have allergies?
43. Have you ever had cataracts?
44. Do your wounds, cuts, and bruises heal slowly?
45. Do you have loose teeth or gums that bleed when you brush or floss?
46. Do you get frequent sore throats?
47. Do you ever experience rectal itching?
48. Do you grind your teeth at night or sometimes pick your nose?
49. Do you have any house pets?
50. Have you ever traveled to a "Third-world" country?
51. Have you ever been diagnosed as having parasites?
52. Do you ever eat pork products - ham, bacon, pork chops, pork ribs?
53. Do you burp after eating?
54. Do you have bad breath frequently?
55. Do you need to use antacids occasionally?
56. Do you sometimes feel bloated after a meal?
57. Do you frequently have gas?
58. Do you occasionally experience heartburn?
59. Are you suffering from gum disease?
60. Do you have arthritis or osteoporosis of any kind?
61. Do you have achy or swollen joints?
62. Turn your neck from side to side--do you hear a cracking/scraping noise?
63. Do your fingernails split or peel horizontally?
64. Do you have dark circles under your eyes much of the time?
65. Do your cheeks seem to have lost a natural, rosy color?
66. Do you drink more than 2 cups of coffee or black tea daily?
67. Do you have an irregular heartbeat?
68. Do you need to use laxatives or experience diarrhea frequently?
69. Do you have weak muscles or do your muscles cramp?
70. Do you use Licorice Root herb daily?
71. Do you occasionally feel slightly shaky, light headed, "spacey", or "on edge"?
72. Do you have sluggish intestines with gas accumulations?
73. Do you use diuretics (drugs, not herbs)?
74. Do you have little white specks on your fingernails?
75. Do you heal slowly when you cut yourself?
76. If you are male, do you have trouble voiding completely?
77. If you are male, do you urinate frequently during the day or several times at night?
78. Have you had a loss of sense of taste, smell, or hearing?
79. Do you sometimes experience constipation (less than one bowel elimination a day)?
80. Do the bottoms of your feet hurt when you first get out of bed in the morning?
81. Do you take a fiber supplement daily? Check this IF THE ANSWER IS NO.
82. Do you occasionally have intestinal gas or sharp pain(s) in your abdomen (below your waist)?
83. Do you have loose stools or diarrhea frequently?
84. Are your stools either watery or quite hard?
85. Do you sleep poorly or feel fatigued much of the time?
86. Do you use alcohol and/or dairy products on a daily basis?
87. Do you ever get muscle tremors, leg cramps, or muscle spasms?
88. Are you menopausal or post-menopausal or do you have osteoporosis or kidney stones?
89. Are you ever bothered by nervous twitches or "tics" or feel very nervous at times?
90. Do you have heart disease or cardiac arrhythmias?
91. Do you feel stressed or anxious much of the time?
92. Does you tongue or mouth get sore occasionally?
93. Do you have Herpes of the mouth or genitalia?
94. Do you ever get canker sores or cold sores?
95. Do you ever get unexplained skin rashes, fungus infections, vaginitis or "jock itch", or recurring kidney/bladder infections?
96. Do you have stomach or duodenal ulcers?
97. Do you have a hiatal hernia or do you experience a burning sensation in the throat or chest when you lie down?
98. Is it hard to eat a meal without feeling an upset stomach?
99. Do you feel nauseated when you are nervous or hungry?
100. Do you experience pain (s) in your stomach for which you use antacids occasionally?
101. Do you have trouble digesting fats?
102. Do you have a high cholesterol or triglyceride level?
103. Do you have heart trouble?
104. Do you have cold hands & feet?
105. Are you extremely uncomfortable when it is quite cold?
106. Would you like to be able to take a nap in the middle of the afternoon?
107. Do your fingers tremble when you hold them straight out?
108. Is your hair dry & brittle or thin?
109. Does your heart beat very fast after exerting yourself?
110. Are you uncomfortable when it is very hot?
111. Do you get extremely thirsty frequently?
112. Do you have mood swings, feeling fine one moment and "down in the dumps" the next?
113. Do you feel that you urinate large amounts?
114. Have you ever been diagnosed as having diabetes?
115. Does your breath ever smell sweet?
116. Do you crave sweets, cigarettes, coffee or cola drinks between meals?
117. Do you have low blood pressure?
118. Do you often feel shaky or confused?
119. Do you have low blood sugar or hypoglycemia?
120. Do you have a weight problem?
121. Are your hands and feet often cold or do they "fall asleep" easily?
122. Do your ankles swell toward the end of the day or do your legs feel heavy?
123. Have you ever had high blood pressure?
124. Do you have varicose veins or hemorrhoids?
125. Do you feel nervous and anxious much of the time?
126. Do little things make you crabby or grouchy?
127. Do you worry about what others think of you?
128. Do your hands shake when you are excited or upset?
129. Are you very concerned about your appearance and/or your house?
130. Do you consider yourself an "over-achiever"?
131. Is it hard for you to catch your breath when exerting yourself?
132. Are you a shallow breather?
133. Do you have respiratory allergies or asthma?
134. Do you have a chronic cough?
135. Do you frequently have nausea, gas, or bloating after eating?
136. Do you ever have pain on the right side under your rib cage or between your shoulder blades?
137. Do you have gallbladder trouble or have you had gallbladder surgery?
138. Have you ever had or do you have hepatitis?
139. Females: Do you have have "female problems", fibroids, hemorrhaging, or hot flashes?
140. Do you ever experience back-aches in the waist area?
141. Do you ever suffer from kidney or bladder infections?
142. Do you have frequent or painful urination?
143. Do you have repeated or chronic sinus congestion or sinus infections?
144. Do you have vaginal itching or discharge frequently (females) or "jock itch" (males)?
145. Have you recently had or do you currently have a fungus infection or Athletes' Foot?
146. Do you get frequent or recurring bladder, kidney, or prostate infections?
147. Have you ever had thrush in your mouth or any unexplained skin rashes that come and go?
148. Did you use antibiotics, sulpha drugs, steroids, or birth control pills previous to the occurrence of the above problems?

Now, if time permits, please reread all of these questions and see if you missed any of your symptoms. Careful thought to the questions assures more accurate test results. Then, press the button below when ready.


Site last updated 9/12/16

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Information on this site is provided for educational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. You should read carefully all product packaging. If you have or suspect that you have a medical problem, promptly contact your health care provider. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any disease.

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