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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
Metabolic Screening Questionnaire

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


POINT SCALE:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe

HEAD Headaches
0 1 2 3 4
  Faintness 0 1 2 3 4
  Dizziness 0 1 2 3 4
  Insomnia 0 1 2 3 4
Total

EYES Watery or itchy eyes 0 1 2 3 4
  Swollen, reddened or sticky eyelids 0 1 2 3 4
  Bags or dark circles under eyes 0 1 2 3 4
  Blurred or tunnel vision
(does not include near- or far-sightedness)
0 1 2 3 4
Total

EARS Itchy ears 0 1 2 3 4
  Earaches, ear infections 0 1 2 3 4
  Drainage from ear 0 1 2 3 4
  Ringing in ears, hearing loss 0 1 2 3 4
Total

NOSE
Stuffy nose
0 1 2 3 4
  Sinus problems 0 1 2 3 4
  Hay fever 0 1 2 3 4
  Sneezing attacks 0 1 2 3 4
 
Excessive mucus formation
0 1 2 3 4
Total

MOUTH/THROAT Chronic coughing 0 1 2 3 4
  Gagging, frequent need to clear throat 0 1 2 3 4
  Sore throat, hoarseness, loss of voice 0 1 2 3 4
  Swollen or discolored tongue, gums, lips 0 1 2 3 4
  Canker sores 0 1 2 3 4
Total

SKIN Acne 0 1 2 3 4
  Hives, rashes, dry skin 0 1 2 3 4
  Hair loss 0 1 2 3 4
  Flushing, hot flashes 0 1 2 3 4
  Excessive sweating 0 1 2 3 4
Total

HEART Irregular or skipped heartbeat 0 1 2 3 4
  Rapid or pounding heartbeat 0 1 2 3 4
  Chest pain 0 1 2 3 4
Total
LUNGS Chest congestion 0 1 2 3 4
  Asthma, bronchitis 0 1 2 3 4
  Shortness of breath 0 1 2 3 4
  Difficulty breathing 0 1 2 3 4
Total

DIGESTIVE TRACT Nausea, vomiting 0 1 2 3 4
  Diarrhea 0 1 2 3 4
  Constipation 0 1 2 3 4
  Bloated feeling 0 1 2 3 4
  Belching, passing gas 0 1 2 3 4
  Heartburn 0 1 2 3 4
  Intestinal/stomach pain 0 1 2 3 4
Total

JOINTS/MUSCLE Pain or aches in joint 0 1 2 3 4
  Arthritis 0 1 2 3 4
  Stiffness or limitation of movement 0 1 2 3 4
  Pain or aches in muscles 0 1 2 3 4
  Feeling of weakness or tiredness 0 1 2 3 4
Total

WEIGHT Binge eating/drinking 0 1 2 3 4
  Craving certain foods 0 1 2 3 4
  Excessive weight 0 1 2 3 4
  Compulsive eating 0 1 2 3 4
  Water retention 0 1 2 3 4
  Underweight 0 1 2 3 4
Total

ENERGY/ACTIVITY Fatigue, sluggishness 0 1 2 3 4
  Apathy, lethargy 0 1 2 3 4
  Hyperactivity 0 1 2 3 4
  Restlessness 0 1 2 3 4
Total

MIND Poor memory 0 1 2 3 4
  Confusion, poor comprehension 0 1 2 3 4
  Poor concentration 0 1 2 3 4
  Poor physical coordination 0 1 2 3 4
  Difficulty in making decisions 0 1 2 3 4
  Stuttering or stammering 0 1 2 3 4
  Slurred speech 0 1 2 3 4
  Learning disabilities 0 1 2 3 4
Total

EMOTIONS

Mood swings 0 1 2 3 4
  Anxiety, fear, nervousness 0 1 2 3 4
  Anger, irritability, aggressiveness 0 1 2 3 4
  Depression 0 1 2 3 4
Total

OTHER Frequent illness 0 1 2 3 4
  Frequent or urgent urination 0 1 2 3 4
  Genital itch or discharge 0 1 2 3 4
Total




Copyright HealthComm International, Inc. Form 14 R11/4/94