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
Nutrient Supplementation 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


INSTRUCTIONS

Where several symptoms are listed on one line, answer the question even if only one of the symptoms listed applies to you. Score your symptoms as follows:

0 = Does not apply
1 = Mild
2 = Moderate
3 = Severe

DIET AND DIGESTION
Section A

1. Distress from fats or greasy foods (nausea, dizziness, headaches, etc.) 0 1 2 3
2. Distress from onions, cabbage, radishes, cucumbers bloating, gas, etc. 0 1 2 3
3. Stool appears yellow or clay-colored, is foul-odor or has undigested foods. 0 1 2 3
4. Skin is grayish, pasty, oily on nose and forehead. 0 1 2 3
5. Have had jaundice, hepatitis. 0 1 2 3
6. Bad breath, bad taste in mouth, body odor (including feet). 0 1 2 3
7. Unusual redness on palms of hands. 0 1 2 3
8. Unaccountable burning on soles of feet. 0 1 2 3
9. Varicose veins, hemorrhoids (piles), phlebitis, veins show on chest or stomach (blush areas). 0 1 2 3
10. Able to go all day without urinating, diminished urination. 0 1 2 3
11. History of constipation. 0 1 2 3
12. "Flabby" flesh, underarm or stomach hangs.
0 1 2 3
Total Section A:

Section B
1. Indigestion 2 to 3 hours after each meals (fullness, bloating, sourness, etc.). 0 1 2 3
2. Heavy, full loggy feeling after eating a meat meal. 0 1 2 3
3. Loss of former taste or craving for meat. 0 1 2 3
4. Excessive lower bowel gas (flatulence, failing). 0 1 2 3
5. History of being anemic, treatment for anemia. 0 1 2 3
6. History of constipation alternating with diarrhea bowels "too loose or too tight". 0 1 2 3
Total Section B:

Section C
1. Stomach pain after eating, especially at night, which is relieved by drinking milk or cream. 0 1 2 3
2. Above symptoms flare up in Spring and Fall of the year (seasonal occurrence). 0 1 2 3
3. Have been told you have stomach "ulcers." 0 1 2 3
4. Above symptoms aggravated by worry and tension, relieved by vacationing. 0 1 2 3
Total Section C:
Section D
1. Diarrhea Occurs frequently or is resistant to treatment. 0 1 2 3
2. Roughage in diet aggravates diarrhea. 0 1 2 3
3. Mucous shreds appear in stool. 0 1 2 3
4. Have more than three bowel movements per day. 0 1 2 3
5. Have been told you have ulcerative or mucous colitis. 0 1 2 3
6. Indigestion occurs soon after eating. 0 1 2 3
7. Indigestion is acute, comes on suddenly. 0 1 2 3
8. Indigestion is relieved by soft drinks. 0 1 2 3
9. Belching, stomach cramps, colicky, or "butterfly" sensations in stomach. 0 1 2 3
10. Above symptoms aggravated by stress. 0 1 2 3
Total Section D:
HEART, LUNGS, NERVES, AND BLOOD VESSELS
Section A

1. Eyes are sensitive to bright lights, need to wear sunglasses for comfort. 0 1 2 3
2. Tightness in throat, painful "lump" occasionally. 0 1 2 3
3. Form gooseflesh easily, sweat without temperature rise, "cold sweats"? 0 1 2 3
4. Voice rises to high pitch or is lost during stressful moments. 0 1 2 3
5. Easily shaken up, easily startled, heart pounds hard from unexpected noise. 0 1 2 3
6. Prefer being alone, uneasy when "center of attention." 0 1 2 3
7. Blood pressure fluctuates, has been "too high" on occasion. 0 1 2 3
8. Asthma or wheezes (from). 0 1 2 3
9. Have always had low or normal blood pressure. 0 1 2 3
10. Known as "perfectionist" or come from "high-strung family." 0 1 2 3
11. Tend to work off worries, something left undone causes unusual concern. 0 1 2 3
12. Tend to avoid complaints, try to ignore discomforts and inconveniences. 0 1 2 3
13. Have had frequent or severe attacks of pneumonia, bronchitis, flu, sinusitis, or colds. 0 1 2 3
14. Allergic responses, e.g., skin rash, dermatitis, hay fever, severe sneezing attacks, asthma. 0 1 2 3
15. Emotional storms cause exhaustion (must go lie down under heavy stress). 0 1 2 3
16. Perspire excessively. 0 1 2 3
17. Skin takes on a brownish color, brown spots on skin ("liver spots"). 0 1 2 3
18. Painful finger joints, rheumatoid arthritis, or morning stiffness. 0 1 2 3
Total Section A:
Section B
1. Persistent high blood pressure. 0 1 2 3
2. Stronger than average physically. 0 1 2 3
3. Strong feelings, tendency to "blow up," dislike of being crossed. 0 1 2 3
4. FEMALE: Excessive hair (face, arms, and legs), appearance "masculine." 0 1 2 3
5. MALE: Baldness, excessive hair (arms and back), muscular "square" build, aggressive in business and sports. 0 1 2 3
Total Section B:
Section C
1. Unable to hold your breath for 20 seconds (timed by watch). 0 1 2 3
2. Sigh and yawn frequently. 0 1 2 3
3. Have a feeling of suffocation, open windows in closed rooms. 0 1 2 3
4. Feel short of breath at times, even tough not exercising. 0 1 2 3
5. Feel breathless when under stress. 0 1 2 3
6. Breathe loudly (people notice), heard breathing in quiet rooms. 0 1 2 3
Total Section C:
METABOLISM
Section A

1. Muscles stiff in the morning, feel "creaky" after sitting still for some time. 0 1 2 3
2. Feel dizzy or nauseated in the morning. 0 1 2 3
3. Motion sickness when traveling or dizziness when changing positions. 0 1 2 3
4. Heart occasionally seems to miss beats or "turn flip-flops." 0 1 2 3
5. Coughing, hoarseness, muscle cramps are worse at night. 0 1 2 3
6. Insomnia, restlessness, failing memory, forgetfulness. 0 1 2 3
7. Feel better in afternoon, worse in morning. 0 1 2 3
8. Have an unusual craving for salt. 0 1 2 3
Total Section A:
Section B
1. "Go to pieces" easily, dislike pressure or being watched, cry easily. 0 1 2 3
2. Gain weight, fail to lose on diets, tend to "retain water" easily. 0 1 2 3
3. Long history of chronic constipation. 0 1 2 3
4. Feel better mornings, worse afternoons. 0 1 2 3
5. Difficulty concentrating, easily distracted. 0 1 2 3
6. Outer third of eyebrow hair unusually thin or missing. 0 1 2 3
Total Section B:
Section C
1. Heart beats above 90 beats per minute when at complete rest. 0 1 2 3
2. Protruding tongue quivers (check in minor), hands shake/tremor (hold paper to check). 0 1 2 3
3. Energy spurts followed by exhaustion (repeated in cycles). 0 1 2 3
4. Have strong, healthy teeth. 0 1 2 3
5. Have a good appetite, but fail to gain weight in spite of food increase. 0 1 2 3
6. Have fine features, thin skin, thin hair. 0 1 2 3
7. Erratic behavior, "flightily." 0 1 2 3
8. Poor balance (close your eyes and stand on one leg). 0 1 2 3
Total Section C:
HORMONE, ENDOCRINE, AND ENZYME INDICATIONS
FEMALE:

1. Irregular or uncomfortable menstrual periods. 0 1 2 3
2. Menopause symptoms (hot flashes, etc.). 0 1 2 3
3. Had a "female operation?" 0 1 2 3
4. Before periods feel nervous, depressed, "bloated." 0 1 2 3
5. Unable to have children because of sterility (not age or operation). 0 1 2 3
Total Female:
MALE:
1. Difficulty urinating (slow starting, burning during, need to get up nights). 0 1 2 3
2. Associate the above with back or leg pains, constipation. 0 1 2 3
3. Have/had prostate trouble or surgery. 0 1 2 3
4. Have/had painful, green, or mucous discharge from the penis. 0 1 2 3
Total Male:
MALE AND FEMALE:
1. Muscle weakness, weak grip, weak legs, objects feel unusually heavy. 0 1 2 3
2. Muscles wasting. 0 1 2 3
3. Sharp pains in chest after exercising. 0 1 2 3
4. Numbness or loss of sensation. 0 1 2 3
5. Night sweats, wake up frightened. 0 1 2 3
6. Objects fall from hands, reach in the wrong places for things. 0 1 2 3
7. Blurred vision, bloodshot eyes, feeling of sand or grit in eyes. 0 1 2 3
8. Redness, irritation of nostrils; corners of mouth cracked, irritated 0 1 2 3
9. Lost or diminished sex drive. 0 1 2 3
Total Male and Female:
FLUID BALANCE
Section A
1. Feel drowsy, chronic fatigue. 0 1 2 3
2. Cold hands and feet; wear extra clothing, bed clothing; use heating pads. 0 1 2 3
3. Short of breath climbing stairs. 0 1 2 3
4. Require extra sleep. 0 1 2 3
5. Feel better when resting; lowered endurance, low exercise tolerance. 0 1 2 3
6. Treated for heat prostration; uncomfortable in or dislike hot weather. 0 1 2 3
7. Ankles swell in hot weather. 0 1 2 3
8. Ankles swell in afternoon, improve in morning. 0 1 2 3
9. Perspire excessively in hot weather (more than others). 0 1 2 3
l0. Use very little salt, restricting salt in diet. 0 1 2 3
Total Section A:
SKIN AND IMMUNE DEFENSES
1. Bruise easily, "black and blue spots." 0 1 2 3
2. Have or had protein or albumin in urine; kidney trouble. 0 1 2 3
3. Irritated skin, chapped lips, cracked skin on hands. 0 1 2 3
4. Fungus under nails of hand or feet. 0 1 2 3
5. Skin is rough, dry, scaly, "lumpy." 0 1 2 3
6. Discharge from eyes; "sand" on lids in the morning. 0 1 2 3
7. Burning or itching when urinating. 0 1 2 3
8. Swelling of glands in neck (salivary). 0 1 2 3
9. Swelling of lymph glands. 0 1 2 3
10. Inability to adjust eyes when entering dark room or theater. 0 1 2 3
11. Night Sweats. 0 1 2 3
Total:
ENVIRONMENT AND ADAPTATION
Section A
1. Nervousness, shaky feeling, or headaches are relieved by eating sweets. 0 1 2 3
2. Irritable if late for a meal or miss a meal; irritable before breakfast. 0 1 2 3
3. Experience sudden strong craving for sweets or alcohol. 0 1 2 3
4. Get hungry "five minutes after eating." 0 1 2 3
5. Often wake up at night feeling hungry. 0 1 2 3
Total Section A:
Section B
1. Night sweats, increased thirst. 0 1 2 3
2. Chronic fatigue, lowered resistance. 0 1 2 3
3. History of boils, leg sores, or lesions taking a long time to heal. 0 1 2 3
4. Overweight; trouble losing weight. 0 1 2 3
5. Experience "pickup" from exercising. 0 1 2 3
6. Have/had sugar in urine, diabetes. 0 1 2 3
7. Member of family has diabetes. 0 1 2 3
8. Crave sweets, but eating them does not relieve symptoms. 0 1 2 3
Total Section B:
LIFE EXPERIENCES

Now we will modify your score based on a few life experiences:

1. Do you have your tonsils?
    Yes Subtract 3 points
    No Add 3 points
2. Add one point for each minor surgery:
3. Add two points for each major surgery:

Total for Life Experiences:

Grand Total of All Points:

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