Identification information:

Name:

E-mail address where you wish your analysis sent:

Have you completed this test before? Yes  No 

Are you especially interested in weight loss? Yes  No 

General Background Information:

Age: 

Sex: 

Height: 

Weight: 

Describe the environment where you spend most of
your time (air quality, light quality, etc.). 

Describe any special diet you are currently following.

Do you frequently take aspirin, antacids or
any other non-prescription medicines?

   Yes       No

Do you often eat in fast food restaurants?

Yes  No  

Do you smoke?  Yes  No 

List any information you think should be taken into consideration
when evaluating your state of nutritional health. 

 

Put a 1, 2 or 3 (only) in the box by each question that applies to you.
If your symptom is mild, put a 1. If it is medium, put a 2
and if you have a stong symptom put a 3.

1. Is your hair dry? (answer only as per instructions above)
2. Is your hair brittle?
3. Is your hair dull or lifeless?
4. Is your hair oily?
5. Is your hair falling out?
6. Is your hair thin?
7. Is your hair prematurely grey?
8. Do you have cowlicks?
9. Do you have dandruff?
10. Does your hair grow slowly?
11. Do you have acne?
12. Do you get pimples or blackheads, especially on your upper back or shoulders?
13. Do you get hives?
14. Do you get shingles?
15. Do you have rough, bumpy skin on the backs of your arms?
16. Do you have liver (brown) spots on your skin?
17. Do you have little pink spots or broken capillaries on your skin?
18. Do you get warts?
19. Do you have eczema or psoriasis?
20. Do you get dermatitis or other skin rashes?
21. Do you perspire excessively?
22. Do you feel cold and sweaty or get gooseflesh?
23. Do you feel warm and flushed at normal temperatures?
24. Is your skin warm, moist and fine textured?
25. Is your skin greasy and scaly around your mouth, nose or eyes?
26. Is your skin oily on your nose and forehead?
27. Do you have dry or cracked skin behind your ears?
28. Is your skin generally dry?
29. Is your skin rough, flaky or scaly?
30. Is your skin itchy?
31. Is your complexion sallow (pale grey/green/yellow tint)?
32. Do the soles of your feet and/or palm of your hands have a yellowish tint?
33. Do you have white patches on your skin (vitiligo)?
34. Is your complexion pale?
35. Do you have pale skin, especially on the palms of your hands?
36. Do you have red or inflamed skin?
37. Do you bruise easily?
38. Is your skin aging rapidly?
39. Do you have enlarged facial pores?
40. Is your skin unusually sensitive to the sun?
41. Do you have puffiness or bloating in your face, or under your eyes?
42. Do you have facial and back pain together?
43. Do you see spots?
44. Are you nearsighted (myopic)?
45. Are your eyes sensitive to bright light (sunlight, glare, headlights, etc.)?
46. Is your eyesight getting worse?
47. Do you have poor night vision or find it difficult to adjust your eyes to the light
                    when entering a dark room?
48. Have you had cataracts?
49. Do the whites of your eyes have red lines in them?
50. Do the whites of your eyes have red blotches in them?
51. Do your eyelids feel gritty, like there is sand under them?
52. Are your pupils unusually large?
53. Do your eyeballs bulge?
54. Do you have dark circles under your eyes? 
55. Do you have puffiness around your eyes or bags under your eyes?
56. Do you get conjunctivitis?
57. Do you have eye inflammations or swollen eyelids?
58. Are your eyes dry?
59. Are your eyes itchy or burning?
60. Do you have sinus problems?
61. Do you have hay fever (sneezing attacks)?
62. Do you have a chronic runny nose?
63. Do you catch colds, flu or respiratory infections easily?
64. Are you losing your sense of smell and taste?
65. Do you have a dry, stuffy nose (that makes you want to pick it)?
66. Do you get nosebleeds?
67. Do you have abscesses in your ears?
68. Do you have a diagonal crease in your earlobe?
69. Do you hear a ringing sound in your ears?
70. Do you stammer?
71. Is your tongue inflamed and/or swollen?
72. Is your tongue bright red or reddish-blue in color?
73. Do you have a white coating on your tongue?
74. Is your tongue sore?
75. Is your mouth dry?
76. Is your mouth sore?
77. Is your tongue blackish in color?
78. Do you have deep cracks in your tongue?
79. Does your tongue have bald spots?
80. Do you get small mouth ulcers or canker sores?
81. Do you get abscesses in your mouth?
82. Do you get cracks or sores in the corners of your mouth?
83. Do you have bad breath and/or a bad taste in your mouth?
84. Do you have a metallic taste in your mouth?
85. Do you have a burning feeling in your mouth and throat?
86. Does your tongue quiver when you stick it out?
87. Do you have more than the usual number of cavities?
88. Do you have white, yellowish or brown mottled teeth or discolouration of teeth?
89. Are your teeth pitted?
90. Do your gums bleed easily?
91. Do your gums get inflamed or swollen?
92. Are your teeth loose and do you lose dental fillings?
93. Are your teeth sensitive?
94. Are your teeth crowded with poor placement in your mouth?
95. Do you have a tingling sensation in your lips?
96. Are your lips constantly chapped?
97. Are your lips red, white, scaly or swollen?
98. Does your upper lip appear to be shrinking?
99. Are the lymph glands in your neck enlarged?
100. Do you have more than usual neck, head and shoulder tension?
101. Does your voice rise to a high pitch, or disappear when you're nervous?
102. Does your throat feel tight and sore when you're upset? 
103. Do you have difficulty swallowing?
104. Do you have an enlarged thyroid gland (goitre)?
105. Do you cough and get hoarse, especially at night?
106. Are your joints tender?
107. Do you have pains in your joints?
108. Do you have joint pains that tend to be vague and fleeting?
109. Are your joints stiff or swollen?
110. Do you have arthritis?
111. Are your joints creaking or clicking? 
112. Does your spine hurt?
113. Are your muscles weak (do you have a weak grip)?
114. Are your muscles tender?
115. Do you have muscular swelling?
116. Do you have muscular wasting in any part of your body?
117. Do your muscles twitch and/or do you get nervous ticks?
118. Do you have muscle spasms and aching muscles?
119. Do you get muscle tremors, convulsions or seizures?
120. Do you gets pains in your muscles?
121. Do you get muscle cramps?
122. Do you get cramps in your calf muscles during sleep or exercise?
123. Are your muscles stiff in the morning and need to be limbered up?
124. Are your muscles unusually sore or stiff after exercising?
125. Do you have poor muscle tone?
126. Do you have Muscular Dystrophy?
127. Do you have loss of ligament tone or strength?
128. Do you have numbness or heaviness in your arms or legs?
129. Do you have stiffness in your arms or legs?
130. Do your arms and/or legs go to sleep?
131. Do you have pain in your forearm or biceps?
132. Do your arms and/or legs jerk?
133. Are you susceptible to athletic injuries?
134. Do you have cold hands and/or feet?
135. Do you have pains in your hands and/or feet?
136. Do you have sweating of your hands and feet?
137. Do your hands or feet feel numb or tingly?
138. Do your hands or feet burn?
139. Do you have soreness or weakness in your hands or feet?
140. Do you have swelling of your hands, feet or ankles?
141. Do you get cramps in your hands when writing?
142. Are your hands or feet shaky?
143. Is the skin on the backs of your hands chapped?
144. Are you unable to close your hands into a tight fist?
145. Do you have carpal tunnel syndrome?
146. Are your thumbs tender or weak?
147. Do you have white spots on your fingernails?
148. Do you have ridges on your fingernails?
149. Are your fingernails abnormally light in color?
150. Are your nails brittle?
151. Are your nails thin?
152. Do you get hangnails?
153. Are your fingernails flat or concave?
154. Do your fingers tingle?
155. Do your fingers and/or toes go cold?
156. Is your breathing rapid?
157. Do you have difficulty getting your breath when lying down, or with light exertion?
158. Do you have a persistent, nagging cough? 
159. Do you have asthmatic attacks? 
160. Do you have a history of bronchitis or pneumonia?
161. Do you have emphysema?
162. Do you have an irregular heartbeat (palpitations)?
163. Does your heart do "flip-flops"?
164. Does your heart beat rapidly when you exert yourself, even lightly?
165. Is your resting heartbeat over 90?
166. Is your resting heartbeat slow?
167. Are you easily shaken up or so startled so that your heart pounds?
168. Is your heart enlarged?
169. Do you have cardiomyopathy?
170. Do you have weakened heart tissue?
171. Do you have fluid retention?
172. Do you have high blood pressure?
173. Do you have low blood pressure?
174. Does your blood pressure fluctuate, and is sometimes too low?
175. Do you have high cholesterol?
176. Are you anemic?
177. Do you have hemolytic anemia?
178. Do you have blood sugar disturbances?
179. Do you have a tendency to diabetes?
180. Do you have cystic breast disease?
181. Do you have chest pains after exercise or emotional stress?
182. Do you have lower back pain?
183. Do you have mid-back pains?
184. Do you have general back pains?
185. Do you have difficulty urinating at the same time as you have back or leg pains?
186. Do you have right-sided upper abdominal pain?
187. Do you have vague abdominal aches, discomfort or cramps?
188. Do you have a full, sluggish feeling after a heavy meal?
189. Do you have abdominal bloating?
190. Do you have excessive gas?
191. Do you have belching, accompanied by head colds?
192. Do you have belching after meals?
193. Do you have abdominal bloating after meals?
194. Does your stomach hurt a few hours after eating (especially when you're stressed)
                   and it is soothed by drinking milk?
195. Do you have stomach or bowel pain after eating?
196. Do you have a burning sensation in your stomach? 
197. Do you have a stomach ulcer?
198. Do you feel tired after eating?
199. Do you drink chlorinated water?
200. Do you have indigestion after eating?
201. Do you have indigestion which is not helped by antacids?
202. Do you have heartburn?
203. Do you have difficulty digesting meat or other proteins?
204. Do you avoid eating red meats and/or organ meats?
205. Do you feel less like having sex than you used to?
206. Do you get a burning sensation when urinating, or urinary infections?
207. Do you urinate often? 
208. Do you urinate 3 times or less per day?
209. Do you have to get up to urinate more than a couple of times per night?
210. Do you urinate a large volume (more than 2 quarts) per day? 
211. Are you incontinent?
212. Do you have difficulty starting your flow of urine?
213. Is your urine dark colored and/or foul smelling?
214. Is your urine greenish tinted?
215. Do you have any kidney disease?
216. Do you get diarrhea?
217. Do you have less than one bowel movement daily?
218. Do you get constipated together with bad headaches?
219. Do you have hard bowel movements that are painful?
220. Do you have alternating diarrhea and constipation?
221. Do you have four or more bowel movements per day?
222. Do you have mucous shreds in your stool?
223. Do you have food particles in your stool?
224. Do you have thin, narrow stools?
225. Are your stools dried up looking?
226. Do your stools float and are they clay-colored, yellow and putrid? 
227. Do you have pale or grey stools that float?
228. Are your stools poorly formed?
229. Do you have colitis, spastic colon or irritable bowel syndrome?
230. Have you had a portion of your small intestines or colon removed?
231. Do you have rectal fissures or hemorrhoids?
232. Does your rectum itch?
233. Do you get cramps in your legs?
234. Do you have varicose veins?
235. Do you get restless leg syndrome (constant jerking or motion of the legs at night)?
236. Do you have stiffness or swelling in your ankles, feet or legs?
237. Do your legs often feel heavy?
238. Do you have bow legs or knock knees (rickets)?
239. Have you lost your ankle or knee jerk reflexes?
240. Do you get cramps in your feet or toes?
241. Do you have or have you had cancer?
242. Do you have scleroderma?
243. Do you have erythematosus?
244. Do you have allergies? 
245. Do you have cystic fibrosis?
246. Do you have lupus?
247. Do you have diabetes?
248. Do you have or have your ever had any form of paralysis?
249. Do your sores and cuts heal slowly?
250. Are you intolerant to alcohol or sugar?
251. Do you have cravings for sugar and/or starches?
252. Do you have cravings for coffee or alcohol?
253. Do you have a diet high in refined sugar and/or processed foods?
254. Do you feel like crying often or do you suffer from depression?
255. Do you feel as if your life is without meaning (apathetic)? 
256. Are you moody, with noticeable ups and downs?
257. Do you have nervous irritability or anxiety?
258. Do you suffer from confusion or disorientation?
259. Do you get irritable if you go too long between meals?
260. Are you hyperactive?
261. Do you feel irritable before you have your breakfast?
262. Are you a nervous or restless person?
263. Do you have nervous tics or twitches? 
264. Do you have headaches or nervous feelings that are relieved by eating sweets?
265. Do you have dizziness, light-headedness or nausea?
266. Dizziness in the morning or when you get up from a lying position?
267. Do you feel dizzy, with a burning head pain which goes away when you eat?
268. Do you have poor co-ordination?
269. Do you have tremors?
270. Do you have convulsions or seizures?
271. Do you have problems sleeping?
272. Do you wake in the morning feeling tired?
273. Do you wake up at night feeling hungry?
274. Do you have a short attention span?
275. Do you have a poor memory?
276. Do you have poor short-term memory?
277. Are you unable to remember your dreams?
278. Do you get headaches?
279. Do you get migraines?
280. Do you have light-headedness, fainting or black outs?
281. Do you get motion sickness?
282. Do you have nausea and/or vomiting?
283. Have you lost your appetite?
284. Have you lost weight?
285. Are you anorexic?
286. Do you feel nauseous in the morning?
287. Do you eat a lot, but never gain weight?
288. Are you speedy and talk fast?
289. Do you have hallucinations, delusions, paranoia or schizophrenia?
290. Do you "fall apart" easily and weep?
291. Do you dislike working to a deadline or having someone watch you?
292. Are you easily distracted and find it difficult to concentrate?
293. Do you have mental disturbances or personality changes? 
294. Do you feel mentally sluggish?
295. Have you lost your sense of humour?
296. Are you easily provoked to anger, do you have strong feelings?
297. Do you dislike being the centre of attention?
298. Are you known as a perfectionist?
299. Do you put up with difficulties rather than complain?
300. If upset, do you dive into work? Is leaving tasks unfinished stressful?
301. Have you lost your self-confidence?
302. Do you feel spacey or unreal?
303. Do you tend to be negative?
304. Does being emotionally upset make you totally exhausted?
305. Have you lost your ability to speak?
306. Do you have extreme sensitivity to odors (tobacco, perfume, etc.)?
307. Are you extremely sensitive to noise? 
308. Do you have a craving for salty foods?
309. Do you get extremely tired and rest doesn't seem to help? 
310. Do you have food cravings?
311. Do you crave chocolate?
312. Do you crave ice?
313. Do you eat excessively fast?
314. Have you lost your taste for meat? 
315. Do you feel hungry soon after eating?
316. Do you have an unusual thirst?
317. Do you drink more than three cups of caffeinated coffee per day?
318. Do you drink black or green tea daily?
319. Do you drink less than 2 glasses of water per day?
320. Do you have consistent gas and bloating from most foods?
321. Do cucumbers, radishes, onions and cabbage cause gas and bloating?
322. Do greasy, fatty foods cause headaches and nausea?
323. Are you allergic or sensitive to some foods?
324. Do potatoes disagree with you?
325. Do you avoid eating dark green leafy vegetables?
326. Do you avoid eating raw fruits and vegetables?
327. Do you usually use margarine as a spread or in cooking?
328. Do you consume large amounts of wheat bran?
329. Do you eat deep fried foods on a daily basis?
330. Are you aging prematurely or look older than you really are?
331. Are you a vegetarian?
332. Does your body not respond well even when you exercise regularly?
333. Do you have difficulty losing weight?
334. Do you gain weight easily?
335. Are you overweight?
336. Does your weight go up and down sharply?
337. Do you have night sweats?
338. Do you feel cold when others around you do not?
339. Are you unusually sensitive to extremes in temperature?
340. Do you get infections easily? 
341. Have you been called a hypochondriac?
342. Do you feel really bad for no obvious reason?
343. Do you have minor physical ailments that recur in cycles?
344. Do you feel stiff after being in one position for awhile?
345. Do you have a very strong body odor?
346. Have you used a lot of antibiotics or birth control pills?
347. Do you have stretch marks?
348. Do you have low hormone levels?
349. Do you always feel tired?
350. Do you have bursts of energy which lead to complete exhaustion?
351. Are you a physically weak person?
352. Do you tire out easily?
353. Are you physically stronger than average?
354. Do you have fragile, brittle bones or osteoporosis? 
355. Are your bones poorly developed or malformed?
356. Do you get bone spurs?
357. Do you have osteomalacia (softening of bone)?

Women:
. 
358. Are you infertile?
359. Are you frigid?
360. Do you have a lot of hair on your face, arms and legs?
361. Have you had morning sickness?
362. Have you had a number of miscarriages?
363. Do you have bad cramps and/or heavy bleeding during your periods?
364. Are your periods irregular?
365. Do your periods last more than five days? 
366. Do you have P.M.S.?
367. Do you have any of the symptoms of menopause (hot flashes, etc.)?
368. Do you have vaginal infections, itching, burning or discharge?
369. Do you have endometriosis?
370. Have you had a partial or complete hysterectomy?

Anytime from fourteen days prior to, until two days after your period:

371. does your heart pound?
372. are your breasts tender?
373. do you have backache & cramps?
374. do you have bloating & weight gain?
375. do you crave sweets?
376. feel anxious and nervous?
377. feel irritable and restless?
378. feel depressed?
379. feel dizzy and faint?
380. have insomnia?
381. feel forgetful and confused?
382. get headaches?
383. have increased appetite?
384. get moody, emotional and cry easily?
385. is your acne worse?
386. do your hands and feet swell?

Men:
. 
387. Are you sterile or impotent?
388. Do you have prostate problems?
389. Do you have excess hair on your arms and back?
390. Are you muscular with a square build?
391. Are you aggressive in sports or business?
392. Are you bald?

Please note that I am a Registered Nutritional Consultant. I am not a doctor. As an R.N.C., I do not diagnose or treat disease. Indicate that you understand the importantance of consulting your doctor if you suspect that you have a medical problem.

Yes I understand                            No I do not understand