This questionnaire is designed to assess bodily signs which may relate to nutritional imbalance. Its sole purpose is to educate and to inform. It is not intended to diagnose disease conditions. If you suspect that you may have a medical problem, please seek competent medical care.

To complete this form, simply check the corresponding number if any part of a statement is true for you.

• Select “0” for all statements which do not apply to you
• Select “1” for “sometimes” or “mild”
• Select “2” for “often” or “moderate”
• Select “3” for “very often” or “severe”

Do not “agonize” over any statement. If it is unclear or questionable, ignore it and go on to the next. Please do not try to “match” your answers if the similar symptoms come up in different sections. Go with your gut feeling.

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Please enter your name
Full Name:
Section 1
0	1	2	3
				Indigestion or sourness 2 to 3 hr. after meals.
				Abdominal bloating, distension.
				Full, loggy feeling after heavy meat meal.
				Loss of former taste or craving for meat.
				Excessive gas, belching or burping after meals.
				Heavy, tired feeling after eating.
				Constipation.
				Burning sensation in stomach.
Section 2
0	1	2	3
				Consistent gas & bloating from most foods.
				Fats/greasy foods cause nausea, headaches.
				Onions, cabbage, radishes, cucumbers cause bloating, gas, distress.
				Stool appears yellow, clay-coloured, foul odoured.
				Skin oily on nose and forehead.
				Constipation.
				Bad breath/bad taste in mouth, excess body odour.
Section 3
0	1	2	3
				Diarrhea without apparent cause.
				Mucous shreds in stools.
				Have more then 3 bowel movements per day.
				Painful, hard bowel movements.
				Thin, pencil-like bowel movements.
				Alternating constipation and diarrhea.
				Hemorrhoids or rectal fissure.
Section 4
0	1	2	3
				Excess fluid retention (edema) in hands or feet.
				Nausea or dizziness.
				Poor co-ordination.
				General, overall weakness.
				Anemia.
				Cataracts.
				Catch colds, flu, infections easily.
				Cuticles tear easily.
				Muscle wasting.
				Premature aging.
				Low hormone levels.
				Hair dull, dry, sparse, loose and falling out.
Section 5
0	1	2	3
				Rough, dry, flaky or scaly skin.
				Dry, brittle hair.
				Wounds heal poorly.
				Get infections easily.
Section 6
0	1	2	3
				Brittle fingernails.
				Pain in forearm or biceps.
				Cramps in calf muscle during sleep or exercise.
				Painful cramping of feet or toes.
				Joint pains.
				Teeth crowded, with poor placement in mouth.
				Teeth prone to decay, frequent toothaches.
				Poor quality or malformation of bones.
				Nervous tics or twitches.
				Nervousness or irritability.
				Unusual sensitivity to noise.
				Insomnia.
				Heart palpitations.
				FEMALE: Excessive, lengthy, painful menses.
Section 7
0	1	2	3
				High cholesterol in blood.
				Intolerance to alcohol.
				Glucose intolerance, hypoglycemia, diabetes.
Section 8
0	1	2	3
				Dry hair.
				Brittle nails.
				Slow mental reactions.
				High cholesterol in blood.
				Enlargement of thyroid gland, goiter.
				Heart palpitations.
				Irritability.
				Overweight, obesity.
				Sluggish metabolism.
				Constipation.
Section 9
0	1	2	3
				Pale skin, palms of hands very pale.
				Fingernails very light in colour.
				Fingernails flat or concave (spoon-shaped).
				Thin, fragile, brittle nails.
				Inner side of lower eyelid is pale.
				Lack of endurance or stamina, anemia.
				Cravings for ice, ice eating.
Section 10
0	1	2	3
				Irritable nerves or muscles, nervous tics/twitches.
				Muscle spasms, tremors, convulsions or seizures.
				Irregular heartbeat.
				Painful and cold hands or feet.
				Excessive body odour.
				Loose or sensitive teeth.
				Anxiety, confusion, disorientation, irritability.
				Nausea, dizziness or lightheadedness.
				Mental depression or apathy.
				Hypersensitivity to noise.
				Poor co-ordination.
				Cravings for chocolate.
				Insomnia, restlessness, hyperactivity.
				Bone spurs.
				High blood pressure.
Section 11
0	1	2	3
				Prone to athletic injuries, strained knees, elbow.
				Loss of ligament tone or strength.
				Muscular weakness.
				Nervous degeneration.
Section 12
0	1	2	3
				Swelling of ankles or hands.
				Dry skin.
				Slow, rapid or irregular heartbeat, palpitations.
				Constipation.
				Unusual thirst.
				Unusually sore or stiff muscles after exercising.
				High blood pressure.
Section 13
0	1	2	3
				Muscular degeneration, muscular dystrophy.
				Weakened heart tissue, cardiomyopathy.
				Cancer.
				Cataracts.
				Cystic fibrosis.
Section 14
0	1	2	3
				Cuts, wounds, cores heal slowly.
				Hair or nails grow slowly.
				Loss of sense of smell or taste.
				Catch infections easily.
				Brittle nails.
				White spots on fingernails.
				Acne.
				Stretch marks.
				Sterility or impotence.
				White coating on tongue.
				Loss of appetite, anorexia.
				Sleep disturbances.
				Diarrhea.
				MALE: Prostate problems.
Section 15
0	1	2	3
				Poor night vision, unable to see well in dim light.
				Eyes sensitive to glare, sunlight or bright lights.
				Inability to adjust eyes when entering a dark room.
				Dry eyes.
				Eyelids red, scaly or dry.
				Eye inflammations, discharge, mattering, eyelids swollen or pus laden.
				Get colds or respiratory infections easily.
				Sinus problems.
				Abscesses in ears, mouth or salivary glands.
				Brittle hair.
				Dry, rough or scaly skin.
				Hard "goosebumps" on back of arms that won’t go away.
				Acne, pimples or blackheads.
				Warts.
				Kidney, urinary or bladder infections, burning or itching when urinating.
Section 16
0	1	2	3
				Heart palpitations or gallop rhythm.
				Slow heart beat or rapid heart beat.
				Enlarged heart.
				Diastolic blood pressure over 90.
				Forgetfulness, poor memory, short attention span.
				Muscular tenderness, weakness or wasting.
				Irritability.
				Feel depressed.
				Loss of appetite or loss of weight.
				Numbness, pricking or tingling in hands or feet.
				Loss of ankle or knee jerk reflexes.
				Poor co-ordination.
				Stiffness or swelling in ankles, feet or legs.
				Cramping pains in legs.
				Tenderness in calf muscle under pressure.
				Constipation.
Section 17
0	1	2	3
				Cracks or sores in corner of mouth.
				Reddish-purple (magenta) coloured tongue.
				Shiny, sore or swollen tongue.
				Lips red, white, scaly, swollen or chapped.
				Conjunctivitis.
				Cataracts.
				Sensation of sand on inside of eyelids.
				Eyes sensitive to light or dimming of vision.
				Eyes red, itchy, burning.
				Red lines in whites of eyes.
				See spots before the eyes.
				Abnormally greasy or scaly skin around nose.
				Shrinking or "disappearing" upper lip.
				Falling hair, abnormal hair loss.
				Oily hair.
Section 18
0	1	2	3
				Diarrhea.
				Chapping of backs of hands.
				Itchy, red or inflamed skin, dermatitis.
				Irritability, anxiety or depression.
				Mental aberrations or schizophrenia.
				Loss of sense of humour.
				Indigestion.
				Small ulcers or canker sores in mouth.
				Burning sensation in hands or feet.
				Insomnia.
				Whitish, coated tongue.
				Brilliant red, painful tongue.
				Swollen tongue with red tips and sides.
				Feel as if hands or feet go numb.
Section 19
0	1	2	3
				Irritability or nervousness.
				Feel confused.
				Can’t remember dreams.
				Dizziness.
				Swelling of hands, feet or ankles (edema).
				Unable to close hands into tight, flat fists.
				Soreness, tenderness, weakness of thumb muscles.
				Greasy scaliness on skin near nose, mouth, eyes.
				Greenish tint to urine.
				Muscular twitching.
				Hyperactivity.
				Poor co-ordination in walking.
				FEMALE: Nausea of pregnancy.
				FEMALE: Acne worse during periods.
Section 20
0	1	2	3
				Sore, beefy red tongue.
				Lemon-yellowish tint to skin, pale complexion.
				Numbness, tingling, soreness or weakness in hands or feet.
				Jerking of limbs.
				Memory loss.
				Stammer.
				Apathy, feel as if have lost incentive in life.
				Depression, irritability or moodiness.
				Anemia.
				Paranoia, delusions or hallucinations.
				Loss of appetite.
				Confusion, disorientation or agitation.
				Back pains.
				Dizziness.
				Dimmed vision.
				Poor stomach digestion, low stomach acid.
				FEMALE: Menstrual disturbances.
Section 21
0	1	2	3
				Skin shiny, dry and scaly.
				Tongue purplish-red (magenta) swollen & painful.
				Nausea.
				Muscular pains.
				Mental depression.
				Poor appetite.
				Fingernails a pale colour.
				Sleeplessness.
				Irregular heart beat.
				Hair loss.
				Extreme weariness, exhaustion.
Section 22
0	1	2	3
				Eczema.
				High blood pressure.
				High cholesterol levels.
				Bleeding ulcer.
				Have difficulty losing weight.
Section 23
0	1	2	3
				Tongue red, shiny, smooth and painful.
				Ulcers in mouth.
				Red, swollen or bleeding gums.
				Intestinal malabsorption, sprue.
				Diarrhea.
				Heart palpitations.
				Swelling of ankles.
				Lightheadedness, faintness.
				Apathy or depression.
				Forgetfulness.
				Loss of appetite, weight loss.
				Greying hair.
				Excess pigmentation of skin.
				Irritable, agitated, brooding or self-conscious.
				Anemia.
Section 24
0	1	2	3
				Skin sensitive to sun, photosensitivity.
				White patches on skin, loss of pigment, vitiligo.
				Constipation.
				Irritability.
				Low sex drive.
				Lupus erythematosus.
				Scleroderma.
Section 25
0	1	2	3
				Pupils in eyes are unusually large, dilated.
				Periods of deep depression.
				Burning sensation of hands or feet.
				Poor co-ordination.
				Lightheaded or dizzy when getting up out of a lying or sitting position.
				Diarrhea or constipation.
				Numbness or tingling in hands or feet.
				Joint pains.
				Muscle cramps.
				Rapid heartbeat on exertion.
				Irritability.
				Headaches.
				Insomnia, sleeplessness.
				Fatigue, tiredness, lack of energy.
Section 26
0	1	2	3
				Skin bruises easily, "black & blue" marks.
				Hemorrhages or ruptured blood vessels in eye.
				Gums bleed easily, especially when brushing teeth.
				Bluish-red, swollen or inflamed gums.
				Loose teeth, loss of dental fillings.
				Cuts, sores or wounds heal slowly.
				“Fleeting” pains in joints or legs, joint tenderness.
				Catch infections, colds, flu or viruses easily.
				Listlessness, lack of endurance, tire easily.
				Cuticles tear easily.
				Excessive hair loss.
				Restlessness or irritability.
				Nosebleeds.
				Broken capillaries, hemorrhages or little pink spots on skin.
				Bloating or puffiness in face.
				Anemia.
				Fragile bones.
Section 27
0	1	2	3
				Burning in mouth and throat.
				Poor bone development.
				Abnormal number of dental cavities.
				Osteoporosis (demineralized bone).
				Osteomalacia (softening of bone).
				Rickets (bowlegs, knock-knees).
				Joint pains.
				Muscular cramps.
				Nearsightedness, myopia.
				Nervousness.
				Insomnia.
				Constipation.
Section 28
0	1	2	3
				Muscular swelling or wasting, muscular dystrophy.
				Brittle and falling hair.
				Hemolytic anemia.
				FEMALE: Menstrual discomfort.
				MALE: Low sex drive.
Section 29
0	1	2	3
				Rough skin.
				Excessive perspiration.
				Loss of former taste or craving for meat.
				Nausea, inclination to vomit.
				Potatoes disagree.
				Belching accompanied by head colds.
				Constipation accompanied by throbbing headaches.
				Numbness, stiffness or loss of sensation in arms or legs.
				Stitching or burning in head with dizziness, relieved by eating.
				Poor or failing memory.
Section 30
0	1	2	3
				High or low blood pressure.
				Anemia.
				Emphysema.
				Kidney disease.
Section 31
0	1	2	3
				Nausea or vomiting.
				Abdominal pain.
				Diarrhea.
				Excessive hair loss.
				Hyperactivity, irritability or nervousness.
				Depression.
Section 32
0	1	2	3
				Constipation.
				Cramps or vague abdominal aches or discomfort.
				Dizziness.
				Anxiety or irritability.
				Nervousness or restlessness.
				Lack of ambition, apathy or depression.
				Hand tremors.
				Poor co-ordination.
				Sallow complexion, grayish-greenish-yellow tint.
				Convulsions, seizures.
				Paralysis.
				Catch colds, infections easily.
				Vomiting.
				CHILDREN: Hyperactivity.
Section 33
0	1	2	3
				Tremors or poor co-ordination.
				Inflamed gums.
				Loss of ability to speak.
				High blood pressure.
				Tendency to diabetes.
				Mental disturbances or personality changes.
				Poor memory.
				Depression or uncontrollable crying.
				Metallic taste in the mouth.
				Allergic tendencies.
				Loss of self-confidence.
				Food cravings.
				Facial and back pain.
				Loss of appetite.
				Irritability.
Section 34
0	1	2	3
				High blood pressure.
				Irritability, restlessness, excitement.
				Nausea, vomiting.
				Convulsions.
				Tremors.
				Frequent urination.
				Irregular heartbeat.
				Ringing sound in ear, tinnitus.
Section 35
0	1	2	3
				High blood pressure.
				Shingles, hives.
				Anemia.
Section 36
0	1	2	3
				Whitish, yellowish or brown mottling or discoloration of teeth.
				Pitting of teeth.
				Nausea or vomiting.
				Pain and aching of bones and spine.
Section 37
0	1	2	3
				Excitement.
				Confusion.
				Depression.
				Twitching.
				Abdominal cramps.
				Spasmodic muscular contractions.
				Heart palpitations.
				Rapid breathing.
Section 38
0	1	2	3
				High blood pressure.
				Stools dry, shrunken.
				Excess fluid retention, edema.
				Stomach ulcers.
				Tremors, convulsions or seizures.
				Irritability.
				Excessive thirst or excessive urination.
Section 39
0	1	2	3
				Eyes sensitive to bright lights, headlights, sunlight.
				Tightness or "lump" in throat, hurts when emotionally disturbed.
				Form gooseflesh easily or "cold sweats".
				Voice rises to high pitch or is "lost" during stress, arguments, public appearances, etc.
				Easily shaken up or startled, heart pounds hard from unexpected noice.
				Prefer being alone, uneasy when center of attention.
				Blood pressure fluctuates, sometimes too low.
				Blood pressure decreases when going from a lying position to a standing position.
				Known as a "perfectionist", set high standards.
				Avoid complaints, try to ignore discomforts or inconveniences.
				Work off worries, things left undone cause unusual concern.
				Allergies, such as skin rash, dermatitis, hay fever, severe sneezing attacks, asthma, etc.
				Emotional upsets cause complete exhaustion, must go and lie down when under heavy stress.
				Inferiority complex.
				Unusual craving for salt.
				Perspire excessively.
				Tend to be negative.
				More then usual neck, head, shoulder tension.
Section 40
0	1	2	3
				Persistent high blood pressure.
				Rapid pulse.
				Fluid retention of facial tissues, puffy face.
				Stronger then average physically.
				Strong feelings, tend to "blow up", dislike being crossed.
				FEMALE: Excess hair on face, arms, legs.
				MALE: Baldness, excess hair on arms and back, muscular "square" build, aggressive in business or sports.
Section 41
FEMALE:
0	1	2	3
				Irregular or discomforting menstrual periods.
				Menopausal symptoms: hot flashes, nervousness, depression.
				Have had uterus and/or ovaries removed.
				Lost or diminished sex drive.
				Feel nervous or depressed before periods.
				Unable to have children because of sterility (not because of age or operation).
MALE:
0	1	2	3
				Difficulty urinating – starting, burning.
				Above associated with back or leg pains.
				Have to urinate more then twice during night.
				Prostate trouble or prostate surgery.
				Lost or diminished sex drive.
Section 42
0	1	2	3
				Burning sensation upon urination.
				High diastolic blood pressure (above 90).
				Lower back pains.
				Puffiness around eyes.
				Have to urinate more then twice per night.
				Legs often feel heavy.
				Unable to control flow of urine, incontinence.
				Joint pains.
				Anemia.
Section 43
0	1	2	3
				Pain on inside of left shoulder blade.
				Pain on left side of abdomen.
				Shingles on trunk of body.
				Cold hands or feet.
				Feel cold and sweaty.
				Shakiness.
				Slow healing of wounds, cuts, abraisions.
				Constant, intense thirst.
				Urinate more then 3 liters daily.
				Breath smells sweet or of acetone.
				Peculiar sensations in hands or feet – tingling, burning, sharp jabs, numbmess, etc.
				Vision failing.
				Urine contains sugar.
				Moody with marked ups and downs, elations or depressions, hyperactivity or laziness.
				Vague, unrelated complaints which can be relieved by eating, only to return with a vengeance.
				Cold sweats of the hands even when warm.
				Fainting, blacking out or convulsions.
Section 44
0	1	2	3
				Cold hands or feet, cold all over.
				Infertility or impotence.
				Headaches affection one side of head.
				Excessive urination.
				Left upper neck pain.
				Left little finger pain.
				Overweight from waist down.
				Overweight from waist up.
				Feelings of inadequacy.
				Changeable temperament, moody.
				Feelings dominate over logic.
				Abdominal "apron" of fat.
				Fluid swelling in ankles, fingers, feet or under eyes.
				FEMALE: Loss of menstrual function.
Section 45
0	1	2	3
				Stomach pain 5 or 6 hr. after eating, usually at night, relieved by eating or by drinking milk.
				Above complaints aggravated by worry/tension.
Section 46
0	1	2	3
				Susceptible to flu, infections.
				Swollen glands in armpit, groin, tonsils.
				Feeling of puffiness in throat.
				Soreness on both sides of neck at shoulder level.
				Irregular heartbeat.
				More then usual number of cavities.
				Look older then chronological age.
Section 47
0	1	2	3
				Muscles stiff in morning, feel need to limber up.
				Feel "creaky" after sitting still for some time.
				Heart seems to miss beats or turn "flip-flops".
				These symptoms worse at night: coughing, hoarseness, muscle cramps.
				Nauseated in morning.
				Start slow in morning, gain speed in afternoon.
				Motion sickness when traveling.
				Dizzy in morning or when moving up and down.
				Cold hands or feet.
				Sensitivity to cold, prefer warm climate.
				Hair scanty, dry, brittle, dull, lusterless, lifeless.
				Flaky, dry, rough skin.
				Sleeplessness, restlessness.
				Poor short term memory, forgetfulness.
				Poor response to exercising.
				Hypoglycemia (low blood sugar).
				High cholesterol.
				Constipation, less then one bowel movement daily.
				“Go to pieces” easily, cry easily.
				Dislike working under pressure, being watched.
				Diminished sex drive.
				Gain weight easily, fail to lose on diets.
				Difficulty concentrating, easily distracted.
				Yellowish tint to skin on hands or feet.
				Clogged sinuses.
				Low pulse rate.
				Low body temperature, especially at bed rest.
				Recurrent infections.
				Depression.
				Headaches.
				Puffiness of face or eyes.
				Irritability, mood swings.
				Multiple food allergies/sensitivities.
				FEMALE: Menstrual irregularity, excess flow, premenstrual syndrome.
Section 48
0	1	2	3
				Heart beats above 90 beats per minute at rest.
				Heart palpitations.
				Protruding tongue quivers, hands shake or tremble.
				Strong drive followed by exhaustion.
				Good appetite but fail to gain weight.
				Erratic, "flighty" behaviour, talk rapidly.
				Protruding eyeballs.
				Warm, fine, moist skin.
				Irritability, nervousness, hyperactivity.
				Insomnia.
				Frequent bowel movements, diarrhea.
				Excessive sweating without exercise.
				Feel warm & flushed at normal room temperature.
Section 49
0	1	2	3
				Awake in morning not feeling rested.
				An almost "painful" fatigue not helped by rest.
				Dark or puffy circles under the eyes.
				Spastic colon, colitis, irritable bowel.
				Minor, chronic complaints that recur.
				High blood pressure.
				Bed-wetting, uncontrolled urination.
				Enlargement of lymph glands in neck.
				Have been called a "hypochondriac".
				Insomnia, sleep disturbances.
				Heavy sweating not related to exercise.
				Fluid retention.
				Muscle spasms, aching muscles.
				Painful, stiff or swollen joints.
				Depression or crying spells.
				Sinus attacks.
				Catch colds easily.
				History of bronchitis or pneumonia.
				Hyperactivity.
				Constipation or diarrhea.
				Marked fluctuations in weight.
				Eczema, psoriasis, rashes, dermatitis.
				Irritability.
				Bladder infections.
				Hay fever, sneezing attacks.
				Dry stuffy nose, tendency to pick nose.
				Runny nose.
				Bloating or puffiness in face.
				Bronchial asthma.
				Migraine headaches.
Section 50
0	1	2	3
				Repeated use of antibiotics or birth control pills.
				Cravings for sugars, bread or alcohol.
				Severe reactions to perfume, tobacco or chemical odours.
				Hypersensitivity to certain foods.
				Diarrhea or constipation.
				Rectal itching.
				Bladder infections.
				Coated or sore tongue.
				Feel bad all over, without apparent cause.
				Hives, psoriasis or skin rash.
				Anxiety or depression.
				Tiredness, feelings of being "drained".
				Feeling "spacey" or "unreal".
				FEMALE: Premenstrual tension, menstrual problems, cramps.
				FEMALE: Vaginal discharge, burning, itching.
				FEMALE: Endometriosis, uterine fibroids.
				MALE: Prostate problems, impotence.
Section 51
0	1	2	3
				Fingers and/or toes go cold.
				Arms and/or legs "go to sleep".
				Numbness or heaviness in arms or legs.
				Cramps in hand when writing.
				Sharp, diagonal crease in earlobe.
				Tingling sensation in lips or fingers.
				Short walk causes cramping or pains in legs.
				Memory not as good as it used to be.
				Ankles swell late in day.
				Persistent, nagging cough.
				Breathlessness on slight exertion or lying down.
				Urinate more then twice during night.
				High blood pressure.
				Whitish ring under outer part of cornea in the eye.
				Impotent or frigid.
				Chest pain after physical exertion or emotional stress.
Section 52
0	1	2	3
				Nervousness, shaky feelings or headaches relieved by eating sweets.
				Irritable if late for a meal or miss a meal.
				Irritable before breakfast.
				Sudden, strong cravings for sweets, coffee, or alcohol.
				Asthmatic attacks.
				Get hungry soon after eating.
				Cold hands or feet.
				Wake up at night feeling hungry.
				Wake up in middle of night and can’t go back to sleep.
Section 53
0	1	2	3
				Tremors of hands or feet.
				Double vision.
				Slurred speech.
				Irritability or impatience.
				Loss of stamina while doing physical work.
				Lose temper easily, emotionally unsettled.
Section 54
0	1	2	3
				Muscles weak, weak grip, light objects feel heavy.
				Muscles wasting in some particular part of body.
				Numbness of loss of sensation.
				Objects fall from hands, reach in wrong place for things.
Section 55
FEMALE: (Indicate which conditions apply only if they occur within 14 days prior to and two days after the menstrual period.)
0	1	2	3
				Anxiety, nervous tension.
				Irritability, restlessness.
				Depression.
				Mood swings, emotional outbursts, crying spells.
				Dizziness, fainting.
				Headache.
				Backache, cramps.
				Insomnia.
				Bloating, weight gain.
				Forgetfulness, confusion.
				Increased appetite.
				Craving for sweets.
				Breast tenderness.
				Swelling of hands, feet, edema.
				Pounding heart.
Section 56
0	1	2	3
				Fatigue, tiredness.
				Lack of endurance or stamina.
				Feel depressed, demotivated.
				Irritability or anxiety.
				Sensitivity to cold, more chilly than others.
				Cold extremities (hands, feet, nose).
				Loose or sensitive teeth.
				Inflamed or bleeding gums.
				Kidney stones.
				Osteoporosis.
				Frequent cough, allergies, runny nose.
				Frequent colds, "stomach flu".
				Fragile, brittle nails.
				Cramps, muscle spasms, aching muscles.
				Hair brittle and fall out easily.
				Pain and aching of bones or spine.