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.