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Professional Consultants

DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Elimination Assessment

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:


Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Special Instructions: To answer Question #30 requires that you first perform the 10-day Axillary Temperature Test, click here for instructions.

SECTION A: Colon/Bowel:

1. My bowels move: x day; x week (on the average).

2. Laxative use: x daily; x weekly; x monthly; never.
    Type used:

Answer Codes:
     0 = never
     1 = infrequent
     2 = frequently
     3 = constantly

 

3. My stools are: Large (3 fingers wide and 6" plus in length) 0 1 2 3
  Soft and well-formed (smooth texture) 0 1 2 3
  Medium (2 fingers wide and 4-6 plus in length and well-formed) 0 1 2 3
  Thin, long or narrow stools 0 1 2 3
  Often float 0 1 2 3
  Small and hard 0 1 2 3
  Large and hard 0 1 2 3
  Difficult to pass 0 1 2 3
  Loose, but not watery 0 1 2 3
  Diarrhea 0 1 2 3
  Alternates between hard (constipated) and loose and watery (diarrhea- like) 0 1 2 3
Stool Odor: Offensive usually 0 1 2 3
 
Offensive occasionally
0 1 2 3
  Little odor usually 0 1 2 3
Stool color is: Medium brown, consistently 0 1 2 3
  Dark brown, consistently 0 1 2 3
  Very dark or black 0 1 2 3
  Yellow, light brown or clay colored 0 1 2 3
  Greenish color 0 1 2 3
  Greasy, shiny appearance 0 1 2 3
  Blood is visible in them 0 1 2 3
  Have mucus in them 0 1 2 3
  Varies a lot 0 1 2 3
Intestinal gas: Daily 0 1 2 3
  Occasionally 0 1 2 3
  Excessive 0 1 2 3
  Present with pain 0 1 2 3
  Foul smelling 0 1 2 3
  Little odor 0 1 2 3


4. Do you have trouble initiating your bowel movement, yet the stool is not too large or too hard?

5. Does abdominal discomfort or cramping ever accompany bowel movements?
    How often?

6. Have you ever been diagnosed as having a stomach, liver, gallbladder, pancreas, intestinal or bowel disorder or disease?

    If yes, please explain.

7. Have you had or do you have hemorrhoids or varicose veins? Explain.

8. Do you make a conscious effort to eat a high fiber diet? What do you eat?


9. Do you usually pay attention when nature calls?

SECTION B: Kidney/Bladder:

Answer one:
     Yes
     No
     At Times

10. Do you drink and cook with:
      Reverse Osmosis water
      Distilled water
      Filtered Water

11. Do you drink tap water?

12. How much water do you consume daily?
      No. of Ounces or No. of Quarts

13. Do you feel satisfied that your bladder is completely empty after urinating?

14. Do you have any burning or irritation during or after urination?

15. Do you have difficulty starting or stopping when urinating?

16. Do you get up in the middle of the night to urinate?
      How often? x night; x week.

17. Does your urine have a strong odor to it?
      Is it usually: other

18. At times it has been: other

19. Please list the number and nature of the beverages you drink daily and regularly.


20. Do you get recurrent bladder infections?

21. Do you get unexplained deep lower back pains just below your ribs?


SECTION C: Exercise:

22. Do you exercise regularly?
       x daily; x weekly; x monthly.

23. Please indicate the nature of the exercise and also the number of minutes per session.


24. Do you monitor your pulse while exercising?

      What is your resting pulse rate? beats per minute.

25. Do you perspire with your exercise?

26. Do you perspire other than when exercising?
       When?


27. Do you have difficulty perspiring?

28. Does your perspiration smell strong? Does it smell like urine?

29. Do you get short of breath with even slight exertion?

30. What is your basal temperature? (To answer #30, select the appropriate result from your 10-Day Axillary Temperature Test (ATT). If you have not completed the ATT, print your answers from 1-29, click here for the Axillary Temperature TestInstructions, and then return to complete this questionnaire after performing the Axillary Temperature Test.)(To obtain basal temperature, click here to go to.
What is your basal temperature after performing the 10-day Axilllary Temperature Test?

31. Do you take regular saunas, steam baths or do cold friction rubs?

SECTION D: Occupational/Household:

32. What is your occupation?

     Please describe the work?


33. Do you work in an office building? How many hours per week?
      Do the windows open?

34. Do you have specialized air filtration at your work place?
      What type?

35. Do you work in the-presence of toxic fumes, or chemicals?
      Have you ever?
      Please provide details?


36. Do you smoke?

      How much do you smoke?

 

37. Are you exposed to second hand smoke?

38. Do you drink alcohol?
      What type do you drink?
39. How often do you drink alcohol?

40. Do you use any type of drug (prescription or otherwise)?
     What type/types?

41. How often, what dosage and for what symptom?

      
42. Do any of your hobbies involve toxic materials?
     
If so, what kind (paints, plastics, gases, etc.)?

43. Do you have specialized air filtration at home?
      What type?

44. Do you live in a city?

      How many hours do you spend outside per day?
      Per week?

45. Do you wear sunglasses, contact lenses or glasses when outside?

46. Do you have any respiratory disorders, i.e., Sinusitis, Asthma, Emphysema, Bronchitis, etc.? Please explain.

47. Do you have house pets? What type?


SECTION E: Detoxification:

48. Have you ever conducted a detoxification program supervised by a qualified health professional? Please explain.

49. Do you fast?
      How often and for how long?

50. Are you on a special diet? Please explain.

51. If you avoid any foods or follow a special dietary program, please explain.

52. On the average night, what time do you go to bed?
      What time do you usually rise?
      How many hours do you sleep on the average night?

53. Do you feel well rested on awakening in the morning (ie. ready to rise and get at things)?

54. Do you nap or rest horizontally through the day?
      If yes, for how long on the average?

55. On a scale of 1-10, how do you rate the quality of your sleep (1 being lousy and 10 being perfectly restful)?

Note: This questionnaire is strictly confidential between you and your Clinical Nutritionist. Your accurate responses are vital to effective health care at this office. Please go back over your responses and consider their accuracy. Thank-you!

Copyright 1991, New Health Perspectives, Inc.