Nutrition Response Testing
By the time a person has a diagnosable disease or condition, the body has been suffering
from an imbalance or imbalances for a long time—perhaps decades. During this time, the
body may be compensating so there are no symptoms experienced, or there may be
symptoms that aren't identifiable as a "named condition".
Wouldn't it be great if there were a way to identify these roadblocks to healthy functioning
and to correct them before they become bigger problems? There is. Nutrition Response
Testing TM allows the trained practitioner to locate organs and tissues in the body where
there are imbalances. This is done through a non-invasive testing method involving muscle
testing. This technique is also extremely effective even if a disease or condition has been
diagnosed.
In muscle testing, a muscle that is normally strong will weaken in response to stress
applied to some other part of the body. In Nutrition Response Testing [TM] this stress is
created by the practitioner applying light pressure to the skin over various organs of the
body.
If the area being touched is over (connects to) an organ that is stressed due to an
imbalance, the indicator muscle (usually an arm) will become weak. This is because the
body withdraws resources from the arm to go the aid of the organ. When the correct
nutrition is applied to the body, the arm will "go strong". In this way we can design a precise
nutrition program to address what your body needs. We retest regularly over time to assess
how well the body is responding and to change the nutrition program as needed.
Nutrition Response Testing is one of many tools we use to assess your health and
nutritional needs.
Nutritional Assessment Questionnaire 1.5
Name: ________________________________________________ Date: _____/____/_____
Birth Date: __________________________ Gender: ___________
Please list your five major health concerns in order of importance:
1.
2.
3.
4.
5.
Notes:
PART I. Read the following questions and circle the number that applies:
KEY: 0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly
2 = Consume or use weekly
3 = Consume or use daily
DIET (58)
1. 0 1 2 3 Alcohol
2. 0 1 2 3 Artificial sweeteners
3. 0 1 2 3 Candy, desserts, refined sugar
4. 0 1 2 3 Carbonated beverages
5. 0 1 2 3 Chewing tobacco
6. 0 1 2 3 Cigarettes
7. 0 1 2 3 Cigars/pipes
8. 0 1 2 3 Caffeinated beverages
9. 0 1 2 3 Fast foods
10. 0 1 2 3 Fried foods
11. 0 1 2 3 Luncheon meats
12. 0 1 2 3 Margarine
13. 0 1 2 3 Milk products
14. 0 1 Radiation exposure (0=no, 1=yes)
15. 0 1 2 3 Refined flour/baked goods
16. 0 1 2 3 Vitamins and minerals
17. 0 1 2 3 Water, distilled
18. 0 1 2 3 Water, tap
19. 0 1 2 3 Water, well
20. 0 1 2 3 Diet often for weight control
LIFESTYLE (12)
21. 0 1 2 3 Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a
month)
22. 0 1 2 3 Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
23. 0 1 2 3 Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
24. 0 1 2 3 Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
MEDICATIONS Indicate any medications you’re currently taking or have taken in the last month (0=no, 1=yes): (54)
25. 0 1 Antacids
26. 0 1 Antianxiety medications
27. 0 1 Antibiotics
28. 0 1 Anticonvulsants
29. 0 1 Antidepressants
30. 0 1 Antifungals
31. 0 1 Aspirin/Ibuprofen
32. 0 1 Asthma inhalers
33. 0 1 Beta blockers
34. 0 1 Birth control pills/implant contraceptives
35. 0 1 Chemotherapy
36. 0 1 Cholesterol lowering medications
37. 0 1 Cortisone/steroids
38. 0 1 Diabetic medications/insulin
39. 0 1 Diuretics
40. 0 1 Estrogen or progesterone (pharmaceutical,
prescription)
41. 0 1 Estrogen or progesterone (natural)
42. 0 1 Heart medications
43. 0 1 High blood pressure medications
44. 0 1 Laxatives
45. 0 1 Recreational drugs
46. 0 1 Relaxants/Sleeping pills
47. 0 1 Testosterone (natural or prescription)
48. 0 1 Thyroid medication
49. 0 1 Acetaminophen (Tylenol)
50. 0 1 Ulcer medications
51. 0 1 Sildenafal citrate (Viagra)
PART II (See key at bottom of page)
Section 1 – Upper Gastrointestinal System (55)
52. 0 1 2 3 Belching or gas within one hour after eating
53. 0 1 2 3 Heartburn or acid reflux
54. 0 1 2 3 Bloating within one hour after eating
55. 0 1 Vegan diet (no dairy, meat, fish or eggs) (0=no,
1=yes)
56. 0 1 2 3 Bad breath (halitosis)
57. 0 1 2 3 Loss of taste for meat
58. 0 1 2 3 Sweat has a strong odor
59. 0 1 2 3 Stomach upset by taking vitamins
60. 0 1 2 3 Sense of excess fullness after meals
61. 0 1 2 3 Feel like skipping breakfast
62. 0 1 2 3 Feel better if you don’t eat
63. 0 1 2 3 Sleepy after meals
64. 0 1 2 3 Fingernails chip, peel or break easily
65. 0 1 2 3 Anemia unresponsive to iron
66. 0 1 2 3 Stomach pains or cramps
67. 0 1 2 3 Diarrhea, chronic
68. 0 1 2 3 Diarrhea shortly after meals
69. 0 1 2 3 Black or tarry colored stools
70. 0 1 2 3 Undigested food in stool
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)
Section 2 – Liver and Gallbladder (68)
71. 0 1 2 3 Pain between shoulder blades
72. 0 1 2 3 Stomach upset by greasy foods
73. 0 1 2 3 Greasy or shiny stools
74. 0 1 2 3 Nausea
75. 0 1 2 3 Sea, car, airplane or motion sickness
76. 0 1 History of morning sickness (0 = no, 1 = yes)
77. 0 1 2 3 Light or clay colored stools
78. 0 1 2 3 Dry skin, itchy feet or skin peels on feet
79. 0 1 2 3 Headache over eyes
80. 0 1 2 3 Gallbladder attacks (0=never, 1=years ago,
2=within last year, 3=within past 3 months)
81. 0 1 Gallbladder removed (0=no, 1=yes)
82. 0 1 2 3 Bitter taste in mouth, especially after meals
83. 0 1 Become sick if you were to drink wine (0=no,
1=yes)
84. 0 1 Easily intoxicated if you were to drink wine
(0=no, 1=yes)
85. 0 1 Easily hung over if you were to drink wine (0=no,
1=yes)
86. 0 1 2 3 Alcohol per week (0=<3 1="<7," 2="<14," 3="">14)
87. 0 1 Recovering alcoholic (0=no, 1=yes)
88. 0 1 History of drug or alcohol abuse (0=no, 1=yes)
89. 0 1 History of hepatitis (0=no, 1=yes)
90. 0 1 Long term use of prescription/recreational drugs
(0=no, 1=yes)
91. 0 1 2 3 Sensitive to chemicals (perfume, cleaning
agents, etc.)
92. 0 1 2 3 Sensitive to tobacco smoke
93. 0 1 2 3 Exposure to diesel fumes
94. 0 1 2 3 Pain under right side of rib cage
95. 0 1 2 3 Hemorrhoids or varicose veins
96. 0 1 2 3 Nutrasweet (aspartame) consumption
97. 0 1 2 3 Sensitive to Nutrasweet (aspartame)
98. 0 1 2 3 Chronic fatigue or Fibromyalgia
Section 3 – Small Intestine (47)
99. 0 1 2 3 Food allergies
100. 0 1 2 3 Abdominal bloating 1 to 2 hours after eating
101. 0 1 Specific foods make you tired or bloated (0=no,
1=yes)
102. 0 1 2 3 Pulse speeds after eating
103. 0 1 2 3 Airborne allergies
104. 0 1 2 3 Experience hives
105. 0 1 2 3 Sinus congestion, "stuffy head"
106. 0 1 2 3 Crave bread or noodles
107. 0 1 2 3 Alternating constipation and diarrhea
108. 0 1 2 3 Crohn's disease (0 =no, 1=yes in the past,
2=currently mild condition, 3=severe)
109. 0 1 2 3 Wheat or grain sensitivity
110. 0 1 2 3 Dairy sensitivity
111. 0 1 Are there foods you could not give up (0=no,
1=yes)
112. 0 1 2 3 Asthma, sinus infections, stuffy nose
113. 0 1 2 3 Bizarre vivid dreams, nightmares
114. 0 1 2 3 Use over-the-counter pain medications
115. 0 1 2 3 Feel spacey or unreal
Section 4 – Large Intestine (58)
116. 0 1 2 3 Anus itches
117. 0 1 2 3 Coated tongue
118. 0 1 2 3 Feel worse in moldy or musty place
119. 0 1 2 3 Taken antibiotic for a total accumulated time of
(0=never, 1= <1 2="<3" 3="" month="" months="">3
months)
120. 0 1 2 3 Fungus or yeast infections
121. 0 1 2 3 Ring worm, "jock itch", "athletes foot", nail fungus
122. 0 1 2 3 Yeast symptoms increase with sugar, starch or
alcohol
123. 0 1 2 3 Stools hard or difficult to pass
124. 0 1 History of parasites (0=no, 1=yes)
125. 0 1 2 3 Less than one bowel movement per day
126. 0 1 2 3 Stools have corners or edges, are flat or ribbon
shaped
127. 0 1 2 3 Stools are not well formed (loose)
128. 0 1 2 3 Irritable bowel or mucus colitis
129. 0 1 2 3 Blood in stool
130. 0 1 2 3 Mucus in stool
131. 0 1 2 3 Excessive foul smelling lower bowel gas
132. 0 1 2 3 Bad breath or strong body odors
133. 0 1 2 3 Painful to press along outer sides of thighs
(Iliotibial Band)
134. 0 1 2 3 Cramping in lower abdominal region
135. 0 1 2 3 Dark circles under eyes
Section 5 – Mineral Needs (75)
136. 0 1 History of carpal tunnel syndrome (0=no, 1=yes)
137. 0 1 History of lower right abdominal pains or
ileocecal valve problems (0=no, 1=yes)
138. 0 1 History of stress fracture (0=no, 1=yes)
139. 0 1 2 3 Bone loss (reduced density on bone scan)
140. 0 1 Are you shorter than you used to be? (0=no,
1=yes)
141. 0 1 2 3 Calf, foot or toe cramps at rest
142. 0 1 2 3 Cold sores, fever blisters or herpes lesions
143. 0 1 2 3 Frequent fevers
144. 0 1 2 3 Frequent skin rashes and/or hives
145. 0 1 Herniated disc (0=no, 1=yes)
146. 0 1 2 3 Excessively flexible joints, "double jointed"
147. 0 1 2 3 Joints pop or click
148. 0 1 2 3 Pain or swelling in joints
149. 0 1 2 3 Bursitis or tendonitis
150. 0 1 History of bone spurs (0=no, 1=yes)
151. 0 1 2 3 Morning stiffness
152. 0 1 2 3 Nausea with vomiting
153. 0 1 2 3 Crave chocolate
154. 0 1 2 3 Feet have a strong odor
155. 0 1 2 3 History of anemia
156. 0 1 2 3 Whites of eyes (sclera) blue tinted
157. 0 1 2 3 Hoarseness
158. 0 1 2 3 Difficulty swallowing
159. 0 1 2 3 Lump in throat
160. 0 1 2 3 Dry mouth, eyes and/or nose
161. 0 1 2 3 Gag easily
162. 0 1 2 3 White spots on fingernails
163. 0 1 2 3 Cuts heal slowly and/or scar easily
164. 0 1 2 3 Decreased sense of taste or smell
Section 6 – Essential Fatty Acids (22)
165. 0 1 Experience pain relief with aspirin (0=no, 1=yes)
166. 0 1 2 3 Crave fatty or greasy foods
167. 0 1 2 3 Low- or reduced-fat diet (0=never, 1=years ago,
2=within past year, 3=currently)
168. 0 1 2 3 Tension headaches at base of skull
169. 0 1 2 3 Headaches when out in the hot sun
170. 0 1 2 3 Sunburn easily or suffer sun poisoning
171. 0 1 2 3 Muscles easily fatigued
172. 0 1 2 3 Dry flaky skin or dandruff
Section 7 – Sugar Handling (39)
173. 0 1 2 3 Awaken a few hours after falling asleep, hard to
get back to sleep
174. 0 1 2 3 Crave sweets
175. 0 1 2 3 Binge or uncontrolled eating
176. 0 1 2 3 Excessive appetite
177. 0 1 2 3 Crave coffee or sugar in the afternoon
178. 0 1 2 3 Sleepy in afternoon
179. 0 1 2 3 Fatigue that is relieved by eating
180. 0 1 2 3 Headache if meals are skipped or delayed
181. 0 1 2 3 Irritable before meals
182. 0 1 2 3 Shaky if meals delayed
183. 0 1 2 3 Family members with diabetes (0=none, 1=1 or
2, 2=3 or 4, 3=more than 4)
184. 0 1 2 3 Frequent thirst
185. 0 1 2 3 Frequent urination
Section 8 – Vitamin Need (81)
186. 0 1 2 3 Muscles become easily fatigued
187. 0 1 2 3 Feel exhausted or sore after moderate exercise
188. 0 1 2 3 Vulnerable to insect bites
189. 0 1 2 3 Loss of muscle tone, heaviness in arms/legs
190. 0 1 2 3 Enlarged heart or congestive heart failure
191. 0 1 2 3 Pulse below 65 per minute (0=no, 1=yes)
192. 0 1 2 3 Ringing in the ears (Tinnitus)
193. 0 1 2 3 Numbness, tingling or itching in hands and feet
194. 0 1 2 3 Depressed
195. 0 1 2 3 Fear of impending doom
196. 0 1 2 3 Worrier, apprehensive, anxious
197. 0 1 2 3 Nervous or agitated
198. 0 1 2 3 Feelings of insecurity
199. 0 1 2 3 Heart races
200. 0 1 2 3 Can hear heart beat on pillow at night
201. 0 1 2 3 Whole body or limb jerk as falling asleep
202. 0 1 2 3 Night sweats
203. 0 1 2 3 Restless leg syndrome
204. 0 1 2 3 Cracks at corner of mouth (Cheilosis)
205. 0 1 2 3 Fragile skin, easily chaffed, as in shaving
206. 0 1 2 3 Polyps or warts
207. 0 1 2 3 MSG sensitivity
208. 0 1 2 3 Wake up without remembering dreams
209. 0 1 2 3 Small bumps on back of arms
210. 0 1 2 3 Strong light at night irritates eyes
211. 0 1 2 3 Nose bleeds and/or tend to bruise easily
212. 0 1 2 3 Bleeding gums especially when brushing teeth
Section 9 – Adrenal (78)
213. 0 1 2 3 Tend to be a "night person"
214. 0 1 2 3 Difficulty falling asleep
215. 0 1 2 3 Slow starter in the morning
216. 0 1 2 3 Tend to be keyed up, trouble calming down
217. 0 1 2 3 Blood pressure above 120/80
218. 0 1 2 3 Headache after exercising
219. 0 1 2 3 Feeling wired or jittery after drinking coffee
220. 0 1 2 3 Clench or grind teeth
221. 0 1 2 3 Calm on the outside, troubled on the inside
222. 0 1 2 3 Chronic low back pain, worse with fatigue
223. 0 1 2 3 Become dizzy when standing up suddenly
224. 0 1 2 3 Difficulty maintaining manipulative correction
225. 0 1 2 3 Pain after manipulative correction
226. 0 1 2 3 Arthritic tendencies
227. 0 1 2 3 Crave salty foods
228. 0 1 2 3 Salt foods before tasting
229. 0 1 2 3 Perspire easily
230. 0 1 2 3 Chronic fatigue, or get drowsy often
231. 0 1 2 3 Afternoon yawning
232. 0 1 2 3 Afternoon headache
233. 0 1 2 3 Asthma, wheezing or difficulty breathing
234. 0 1 2 3 Pain on the medial or inner side of the knee
235. 0 1 2 3 Tendency to sprain ankles or "shin splints"
236. 0 1 2 3 Tendency to need sunglasses
237. 0 1 2 3 Allergies and/or hives
238. 0 1 2 3 Weakness, dizziness
Section 10 – Pituitary (29)
239. 0 1 Height over 6' 6" (0=no, 1=yes)
240. 0 1 Early sexual development (before age 10) (0=no,
1=yes)
241. 0 1 2 3 Increased libido
242. 0 1 2 3 Splitting type headache
243. 0 1 2 3 Memory failing
244. 0 1 Tolerate sugar, feel fine when eating sugar
(0=no, 1=yes)
245. 0 1 Height under 4' 10" (0=no, 1=yes)
246. 0 1 2 3 Decreased libido
247. 0 1 2 3 Excessive thirst
248. 0 1 2 3 Weight gain around hips or waist
249. 0 1 2 3 Menstrual disorders
250. 0 1 Delayed sexual development (after age 13)
(0=no, 1=yes)
251. 0 1 2 3 Tendency to ulcers or colitis
Section 11 – Thyroid (48)
252. 0 1 2 3 Sensitive/allergic to iodine
253. 0 1 2 3 Difficulty gaining weight, even with large
appetite
254. 0 1 2 3 Nervous, emotional, can't work under pressure
255. 0 1 2 3 Inward trembling
256. 0 1 2 3 Flush easily
257. 0 1 2 3 Fast pulse at rest
258. 0 1 2 3 Intolerance to high temperatures
259. 0 1 2 3 Difficulty losing weight
260. 0 1 2 3 Mentally sluggish, reduced initiative
261. 0 1 2 3 Easily fatigued, sleepy during the day
262. 0 1 2 3 Sensitive to cold, poor circulation (cold hands
and feet)
263. 0 1 2 3 Constipation, chronic
264. 0 1 2 3 Excessive hair loss and/or coarse hair
265. 0 1 2 3 Morning headaches, wear off during the day
266. 0 1 2 3 Loss of lateral 1/3 of eyebrow
267. 0 1 2 3 Seasonal sadness
Section 12 – Men Only (27)
268. 0 1 2 3 Prostate problems
269. 0 1 2 3 Difficulty with urination, dribbling
270. 0 1 2 3 Difficult to start and stop urine stream
271. 0 1 2 3 Pain or burning with urination
272. 0 1 2 3 Waking to urinate at night
273. 0 1 2 3 Interruption of stream during urination
274. 0 1 2 3 Pain on inside of legs or heels
275. 0 1 2 3 Feeling of incomplete bowel evacuation
276. 0 1 2 3 Decreased sexual function
Section 13 – Women Only (60)
277. 0 1 2 3 Depression during periods
278. 0 1 2 3 Mood swings associated with periods (PMS)
279. 0 1 2 3 Crave chocolate around periods
280. 0 1 2 3 Breast tenderness associated with cycle
281. 0 1 2 3 Excessive menstrual flow
282. 0 1 2 3 Scanty blood flow during periods
283. 0 1 2 3 Occasional skipped periods
284. 0 1 2 3 Variations in menstrual cycles
285. 0 1 2 3 Endometriosis
286. 0 1 2 3 Uterine fibroids
287. 0 1 2 3 Breast fibroids, benign masses
288. 0 1 2 3 Painful intercourse (dysparenia)
289. 0 1 2 3 Vaginal discharge
290. 0 1 2 3 Vaginal dryness
291. 0 1 2 3 Vaginal itchiness
292. 0 1 2 3 Gain weight around hips, thighs and buttocks
293. 0 1 2 3 Excess facial or body hair
294. 0 1 2 3 Hot flashes
295. 0 1 2 3 Night sweats (in menopausal females)
296. 0 1 2 3 Thinning skin
Section 14 – Cardiovascular (30)
297. 0 1 2 3 Aware of heavy and/or irregular breathing
298. 0 1 2 3 Discomfort at high altitudes
299. 0 1 2 3 "Air hunger" or sigh frequently
300. 0 1 2 3 Compelled to open windows in a closed room
301. 0 1 2 3 Shortness of breath with moderate exertion
302. 0 1 2 3 Ankles swell, especially at end of day
303. 0 1 2 3 Cough at night
304. 0 1 2 3 Blush or face turns red for no reason
305. 0 1 2 3 Dull pain or tightness in chest and/or radiate
into right arm, worse with exertion
306. 0 1 2 3 Muscle cramps with exertion
Section 15 – Kidney and Bladder (13)
307. 0 1 2 3 Pain in mid-back region
308. 0 1 2 3 Puffy around the eyes, dark circles under eyes
309. 0 1 History of kidney stones (0=no, 1=yes)
310. 0 1 2 3 Cloudy, bloody or darkened urine
311. 0 1 2 3 Urine has a strong odor
Section 16 – Immune system (30)
312. 0 1 2 3 Runny or drippy nose
313. 0 1 2 3 Catch colds at the beginning of winter
314. 0 1 2 3 Mucus producing cough
315. 0 1 2 3 Frequent colds or flu (0=1 or less per year, 1=2
to 3 times per year, 2=4 to 5 times per year, 3=6
or more times per year)
316. 0 1 2 3 Other infections (sinus, ear, lung, skin, bladder,
kidney, etc.) (0=1 or less per year, 1=2 to 3
times per year, 2=4 to 5 times per year, 3=6 or
more times per year)
317. 0 1 2 3 Never get sick (0 = sick only 1 or 2 times in last
2 years, 1 = not sick in last 2 years, 2 = not
sick in last 4 years, 3 = not sick in last 7 years)
318. 0 1 2 3 Acne (adult)
319. 0 1 2 3 Itchy skin (Dermatitis)
320. 0 1 2 3 Cysts, boils, rashes
321. 0 1 2 3 History of Epstein Bar, Mono, Herpes,
Shingles, Chronic Fatigue Syndrome, Hepatitis
or other chronic viral condition (0 = no, 1 = yes
in the past, 2 = currently mild condition, 3 = severe)
Health Questionnaire (NTAF)
* Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.
Name: _____________________________________Age: ______ Sex: ________ Date:
SECTION A
• Is your memory noticeably declining?
• Are you having a hard time remembering names
and phone numbers?
• Is your ability to focus noticeably declining?
• Has it become harder for you to learn things?
• How often do you have a hard time remembering
your appointments?
• Is your temperament getting worse in general?
• Are you losing your attention span endurance?
• How often do you find yourself down or sad?
• How often do you fatigue when driving compared
to the past?
• How often do you fatigue when reading compared
to the past?
• How often do you walk into rooms and forget why?
• How often do you pick up your cell phone and forget why?
SECTION B
• How high is your stress level?
• How often do you feel that you have something that
must be done?
• Do you feel you never have time for yourself?
• How often do you feel you are not getting enough
sleep or rest?
• Do you find it difficult to get regular exercise?
• Do you feel uncared for by the people in your life?
• Do you feel you are not accomplishing your
life’s purpose?
• Is sharing your problems with someone difficult for you?
SECTION C
SECTION C1
• How often do you get irritable, shaky, or have
lightheadedness between meals?
• How often do you feel energized after eating?
• How often do you have difficulty eating large
meals in the morning?
• How often does your energy level drop in the afternoon?
• How often do you crave sugar and sweets in the afternoon?
• How often do you wake up in the middle of the night?
• How often do you have difficulty concentrating
before eating?
• How often do you depend on coffee to keep yourself going?
• How often do you feel agitated, easily upset, and nervous
between meals?
SECTION C2
• Do you get fatigued after meals?
• Do you crave sugar and sweets after meals?
• Do you feel you need stimulants such as coffee after meals?
• Do you have difficulty losing weight?
• How much larger is your waist girth compared to
your hip girth?
• How often do you urinate?
• Have your thirst and appetite been increased?
• Do you have weight gain when under stress?
• Do you have difficulty falling asleep?
SECTION 1 - S
• Are you losing your pleasure in hobbies and interests?
• How often do you feel overwhelmed with ideas to manage?
• How often do you have feelings of inner rage (anger)?
• How often do you have feelings of paranoia?
• How often do you feel sad or down for no reason?
• How often do you feel like you are not enjoying life?
• How often do you feel you lack artistic appreciation?
• How often do you feel depressed in overcast weather?
• How much are you losing your enthusiasm for
your favorite activities?
• How much are you losing enjoyment for
your favorite foods?
• How much are you losing your enjoyment of
friendships and relationships?
• How often do you have difficulty falling into
deep restful sleep?
• How often do you have feelings of dependency
on others?
• How often do you feel more susceptible to pain?
• How often do you have feelings of unprovoked anger?
• How much are you losing interest in life?
SECTION 2 - D
• How often do you have feelings of hopelessness?
• How often do you have self-destructive thoughts?
• How often do you have an inability to handle stress?
• How often do you have anger and aggression
while under stress?
• How often do you feel you are not rested even
after long hours of sleep?
• How often do you prefer to isolate yourself from others?
• How often do you have unexplained lack of
concern for family and friends?
• How easily are you distracted from your tasks?
• How often do you have an inability to finish tasks?
• How often do you feel the need to consume
caffeine to stay alert?
• How often do you feel your libido has been decreased?
• How often do you lose your temper for minor reasons?
• How often do you have feelings of worthlessness?
SECTION 3 - G
• How often do you feel anxious or panic for no reason?
• How often do you have feelings of dread or
impending doom?
• How often do you feel knots in your stomach?
• How often do you have feelings of being
overwhelmed for no reason?
• How often do you have feelings of guilt about
everyday decisions?
• How often does your mind feel restless?
• How difficult is it to turn your mind off when you
want to relax?
• How often do you have disorganized attention?
• How often do you worry about things you were
not worried about before?
• How often do you have feelings of inner tension
and inner excitability?
SECTION 4 - ACH
• Do you feel your visual memory (shapes &
images) is decreased?
• Do you feel your verbal memory is decreased?
• Do you have memory lapses?
• Has your creativity been decreased?
• Has your comprehension been diminished?
• Do you have difficulty calculating numbers?
• Do you have difficulty recognizing objects & faces?
• Do you feel like your opinion about yourself
has changed?
• Are you experiencing excessive urination?
• Are you experiencing slower mental response?
ideas to manage?
Do you have feelings of paranoia?
Symptom groups listed in this flyer are not intended to be used as a diagnosis of any disease condition.
For nutritional purposes only.
Medication History
Please circle any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
Atropine, Ipratopium, Scopolamine, Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan
Acetylcholinesterase Reactivators
Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine,
Vecuronium, Hemicholine
Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum,
Megadon, Serax , Restoril, Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien, Sonata, Lunesta, Imovane
Cholinesterase Inhibitors (irreversible)
Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine,
Carbamate Insecticidses
Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)
Dopamine Receptor Agonists
Mirapex, Sifrol, Requip
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol,
Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify
GABA Antagonist Competitive binder
Flumazenil
Monoamine Oxidase Inhibitor (MAOI)
Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid
Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)
Remeron, Zispin, Avanza, Norset, Remergil, Axit
Selective Serotonin Reuptake Inhibitor
Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil,
Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine
Selective Serotonin Reuptake Enhancers
Stablon, Coaxil, Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine
Tricylic Antidepresseants (TCAs)
Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil
New Patient Health History
Please be assured that all information on this form and anything discussed during your consultation will be
confidential unless you grant permission otherwise
Name:______________________First Appt date:___________
Address:___________________City:___State:____ Zip_________
Day phone:___________ Evening phone:______ Cell:__________________
Referred by:______________________ YourEmail______________________
Date of Birth:________Age_____Height______Weight_______
Overall Health: circle one Excellent Good Fair Poor
Primary Reason for consultation:________________________
Previous treatments for this problem:____________________
Other concerns or problems____________________________
Current medications or supplements: ( please list all using extra paper if needed)
How many times in your life (approx) have you taken a course of antibiotics?
____1-5 ____5-10 ____more than 10 When was last course of antibiotics (approx.)?____________________
Are you currently under care with any physician or other health care provider. Please give names, date of last visit
and any problems identified at that time:
List all major illnesses or surgeries, accidents or injuries w/ approximate dates:
Please mark any scars on the body diagram included in the packet
List any dental work (fillings, crowns, root canals, extractions, bridges, gum problems)
Are you currently experiencing any dental issues that you are aware of?
Do you drink alcohol? Y N. If yes, how often and typical amount:_____________________________
Have you ever smoked Y N. Do you currently smoke? Y N. How much/day?
Marital Status (circle one) Single Divorced Partnered Married Widowed
How is health of partner? Excellent Good Fair Poor
Number of children if any_____
Do you have any health concerns for your children? Please describe briefly:
Any family history of serious illness or chronic conditions?
Cancer Diabetes Heart Mental Illness Depression/ Anxiety Alcoholism or Substance Abuse Other (please
note)
Any household pets or animals?
Where have you traveled outside of country and when?
What toxic chemicals do you know you are exposed to? Please consider hair chemicals, household cleaning
products, building materials, new furnishings, occupation-related chemicals, lawn, garden and household, etc.
Do you have a regular exercise program? If yes what is it?
What level of stress are you typically under? Low Medium High
What do you do to relieve stress?
What is your occupation and do you enjoy it?
Describe your sleep: ___hard time falling asleep ___broken sleep (wake up but fall back to sleep)
___fall asleep but wake up and can't get back to sleep ___wake up exhausted and dragging in a.m.
Do you live with other people that affect your food habits? What other things affect your food habits?
How willing are you to make dietary changes to address your health concerns?
___a few changes ____moderate _____substantial
Client Summary Sheet Name____________________________________
Special testing notes: ________________________Age: ____
Allergies:
Medication &Contraindications
Weight
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
BMI
___/___/___ _____/______%
___/___/___ _____/______%
___/___/___ _____/______%
Weight Gain Pattern
T A L O P
Blood pressure
Date; BP
Medication ; Contraindications
Contract between Healthy Wealth Survival and
__________________________________ Print client name
The purpose of this contract is to serve as a memorandum of understanding for our work
together.
Here is what you can expect from me:
1. I am a consulting functional nutritionist; I am not a doctor. I do not diagnose illness or
prescribe medication. I am trained to think about how the body systems function, and to
understand health concerns in terms of overall function with a focus on the role of
nutrition. Function improves or degrades along a continuum and as it degrades, one
moves closer toward a diagnosable disease. However, long before a diagnosable
disease or condition happens, we can often identify nutritional deficiencies or other
things that are interfering with healthy functioning, and correct them. My role is to help
you understand how your body works and to look at your symptoms and health concerns
in the context of healthy functioning.
2. I believe in the body's ability to repair itself, if given the right ingredients (quality food, air,
water, and supplements from concentrated food, herbs, homeopathic remedies and
similar non-toxic agents). I believe that most health concerns and symptoms if caught
sooner rather than later can be addressed without the use of pharmaceutical medication,
which, while suppressing symptoms, usually interferes with the body's inherent ability to
self-repair. I do not judge your choice to use or not use pharmaceuticals, however I will
work with you to understand possible alternatives if you ask for that information. I will not
advise you to discontinue any medication that has been prescribed to you. I assume that
if you are choosing to work with me, you are open to learning how you can support your
body in this process of self-healing and I will do my best to share that knowledge with
you through dietary and life-style counseling and through helping you understand how
your body works.
3. I promise to keep our scheduled appointments and to be prepared, present, and ready to
give you the best attention I can.
Here is what I ask from you:
1. My expectation is that you will be open to what may be new ways of looking at your
health and healing, and that you are willing to accept as a goal, taking gradual but
consistent steps to improve your nutritional habits as needed to improve your health.
2. I reserve your appointment time for you, and no one else. Therefore, I respectfully
request that you give me at minimum 24 hours notice if you find it necessary to change your appointment time so that I may offer that spot to someone else. I do charge the
office visit fee for last minute cancellations with limited exceptions for true emergencies.
3. If we have agreed on certain supplements as part of your program, and you have any
concerns in between appointments about your supplements, I would like you to call me
and let me know your concerns rather than waiting until your next visit to have your
concerns addressed.
4. I ask you to agree to a schedule of visits so that we can work together over time to
improve your health and nutritional lifestyle.
5. I ask that if you are pleased with the care and the results you get from our work together
that you refer friends, family and co-workers to Nutrition Magician. Likewise if you have
concerns with your care, I hope you will discuss those with me so that we can find a
positive resolution.
Cost of Services
Initial Health Evaluation $200.00
includes Nutrition Response and Heart Rate Variability (HRV) Testing.
Visits 1-3 45-60 minutes $90
Follow-up Visit 20-25 minutes. $50
Extended Visit per ¼ hour $20.
Email Consultations per ¼ hour $20.
Dietary Consultation 30 / 60 min. $50. / $95.
HRV Testing and report $20.
Phone Consultations (visits 4 and beyond) $60
Center for Functional Nutrition Accepts Visa, Mastercard, Checks and Cash.
Referral Recognition
Our business grows when our clients share their good results with
friends, family, co-workers, and others they care about. We hope you
will support the growth of Healthy Wealth Survival as we support you in
your health. In acknowledgement of the compliment you pay us when
you refer, we gratefully offer you coupons good for products or
services when someone you refer becomes a client. Thank you!
By the time a person has a diagnosable disease or condition, the body has been suffering
from an imbalance or imbalances for a long time—perhaps decades. During this time, the
body may be compensating so there are no symptoms experienced, or there may be
symptoms that aren't identifiable as a "named condition".
Wouldn't it be great if there were a way to identify these roadblocks to healthy functioning
and to correct them before they become bigger problems? There is. Nutrition Response
Testing TM allows the trained practitioner to locate organs and tissues in the body where
there are imbalances. This is done through a non-invasive testing method involving muscle
testing. This technique is also extremely effective even if a disease or condition has been
diagnosed.
In muscle testing, a muscle that is normally strong will weaken in response to stress
applied to some other part of the body. In Nutrition Response Testing [TM] this stress is
created by the practitioner applying light pressure to the skin over various organs of the
body.
If the area being touched is over (connects to) an organ that is stressed due to an
imbalance, the indicator muscle (usually an arm) will become weak. This is because the
body withdraws resources from the arm to go the aid of the organ. When the correct
nutrition is applied to the body, the arm will "go strong". In this way we can design a precise
nutrition program to address what your body needs. We retest regularly over time to assess
how well the body is responding and to change the nutrition program as needed.
Nutrition Response Testing is one of many tools we use to assess your health and
nutritional needs.
Nutritional Assessment Questionnaire 1.5
Name: ________________________________________________ Date: _____/____/_____
Birth Date: __________________________ Gender: ___________
Please list your five major health concerns in order of importance:
1.
2.
3.
4.
5.
Notes:
PART I. Read the following questions and circle the number that applies:
KEY: 0 = Do not consume or use
1 = Consume or use 2 to 3 times monthly
2 = Consume or use weekly
3 = Consume or use daily
DIET (58)
1. 0 1 2 3 Alcohol
2. 0 1 2 3 Artificial sweeteners
3. 0 1 2 3 Candy, desserts, refined sugar
4. 0 1 2 3 Carbonated beverages
5. 0 1 2 3 Chewing tobacco
6. 0 1 2 3 Cigarettes
7. 0 1 2 3 Cigars/pipes
8. 0 1 2 3 Caffeinated beverages
9. 0 1 2 3 Fast foods
10. 0 1 2 3 Fried foods
11. 0 1 2 3 Luncheon meats
12. 0 1 2 3 Margarine
13. 0 1 2 3 Milk products
14. 0 1 Radiation exposure (0=no, 1=yes)
15. 0 1 2 3 Refined flour/baked goods
16. 0 1 2 3 Vitamins and minerals
17. 0 1 2 3 Water, distilled
18. 0 1 2 3 Water, tap
19. 0 1 2 3 Water, well
20. 0 1 2 3 Diet often for weight control
LIFESTYLE (12)
21. 0 1 2 3 Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a
month)
22. 0 1 2 3 Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
23. 0 1 2 3 Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
24. 0 1 2 3 Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
MEDICATIONS Indicate any medications you’re currently taking or have taken in the last month (0=no, 1=yes): (54)
25. 0 1 Antacids
26. 0 1 Antianxiety medications
27. 0 1 Antibiotics
28. 0 1 Anticonvulsants
29. 0 1 Antidepressants
30. 0 1 Antifungals
31. 0 1 Aspirin/Ibuprofen
32. 0 1 Asthma inhalers
33. 0 1 Beta blockers
34. 0 1 Birth control pills/implant contraceptives
35. 0 1 Chemotherapy
36. 0 1 Cholesterol lowering medications
37. 0 1 Cortisone/steroids
38. 0 1 Diabetic medications/insulin
39. 0 1 Diuretics
40. 0 1 Estrogen or progesterone (pharmaceutical,
prescription)
41. 0 1 Estrogen or progesterone (natural)
42. 0 1 Heart medications
43. 0 1 High blood pressure medications
44. 0 1 Laxatives
45. 0 1 Recreational drugs
46. 0 1 Relaxants/Sleeping pills
47. 0 1 Testosterone (natural or prescription)
48. 0 1 Thyroid medication
49. 0 1 Acetaminophen (Tylenol)
50. 0 1 Ulcer medications
51. 0 1 Sildenafal citrate (Viagra)
PART II (See key at bottom of page)
Section 1 – Upper Gastrointestinal System (55)
52. 0 1 2 3 Belching or gas within one hour after eating
53. 0 1 2 3 Heartburn or acid reflux
54. 0 1 2 3 Bloating within one hour after eating
55. 0 1 Vegan diet (no dairy, meat, fish or eggs) (0=no,
1=yes)
56. 0 1 2 3 Bad breath (halitosis)
57. 0 1 2 3 Loss of taste for meat
58. 0 1 2 3 Sweat has a strong odor
59. 0 1 2 3 Stomach upset by taking vitamins
60. 0 1 2 3 Sense of excess fullness after meals
61. 0 1 2 3 Feel like skipping breakfast
62. 0 1 2 3 Feel better if you don’t eat
63. 0 1 2 3 Sleepy after meals
64. 0 1 2 3 Fingernails chip, peel or break easily
65. 0 1 2 3 Anemia unresponsive to iron
66. 0 1 2 3 Stomach pains or cramps
67. 0 1 2 3 Diarrhea, chronic
68. 0 1 2 3 Diarrhea shortly after meals
69. 0 1 2 3 Black or tarry colored stools
70. 0 1 2 3 Undigested food in stool
KEY: 0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=Moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)
Section 2 – Liver and Gallbladder (68)
71. 0 1 2 3 Pain between shoulder blades
72. 0 1 2 3 Stomach upset by greasy foods
73. 0 1 2 3 Greasy or shiny stools
74. 0 1 2 3 Nausea
75. 0 1 2 3 Sea, car, airplane or motion sickness
76. 0 1 History of morning sickness (0 = no, 1 = yes)
77. 0 1 2 3 Light or clay colored stools
78. 0 1 2 3 Dry skin, itchy feet or skin peels on feet
79. 0 1 2 3 Headache over eyes
80. 0 1 2 3 Gallbladder attacks (0=never, 1=years ago,
2=within last year, 3=within past 3 months)
81. 0 1 Gallbladder removed (0=no, 1=yes)
82. 0 1 2 3 Bitter taste in mouth, especially after meals
83. 0 1 Become sick if you were to drink wine (0=no,
1=yes)
84. 0 1 Easily intoxicated if you were to drink wine
(0=no, 1=yes)
85. 0 1 Easily hung over if you were to drink wine (0=no,
1=yes)
86. 0 1 2 3 Alcohol per week (0=<3 1="<7," 2="<14," 3="">14)
87. 0 1 Recovering alcoholic (0=no, 1=yes)
88. 0 1 History of drug or alcohol abuse (0=no, 1=yes)
89. 0 1 History of hepatitis (0=no, 1=yes)
90. 0 1 Long term use of prescription/recreational drugs
(0=no, 1=yes)
91. 0 1 2 3 Sensitive to chemicals (perfume, cleaning
agents, etc.)
92. 0 1 2 3 Sensitive to tobacco smoke
93. 0 1 2 3 Exposure to diesel fumes
94. 0 1 2 3 Pain under right side of rib cage
95. 0 1 2 3 Hemorrhoids or varicose veins
96. 0 1 2 3 Nutrasweet (aspartame) consumption
97. 0 1 2 3 Sensitive to Nutrasweet (aspartame)
98. 0 1 2 3 Chronic fatigue or Fibromyalgia
Section 3 – Small Intestine (47)
99. 0 1 2 3 Food allergies
100. 0 1 2 3 Abdominal bloating 1 to 2 hours after eating
101. 0 1 Specific foods make you tired or bloated (0=no,
1=yes)
102. 0 1 2 3 Pulse speeds after eating
103. 0 1 2 3 Airborne allergies
104. 0 1 2 3 Experience hives
105. 0 1 2 3 Sinus congestion, "stuffy head"
106. 0 1 2 3 Crave bread or noodles
107. 0 1 2 3 Alternating constipation and diarrhea
108. 0 1 2 3 Crohn's disease (0 =no, 1=yes in the past,
2=currently mild condition, 3=severe)
109. 0 1 2 3 Wheat or grain sensitivity
110. 0 1 2 3 Dairy sensitivity
111. 0 1 Are there foods you could not give up (0=no,
1=yes)
112. 0 1 2 3 Asthma, sinus infections, stuffy nose
113. 0 1 2 3 Bizarre vivid dreams, nightmares
114. 0 1 2 3 Use over-the-counter pain medications
115. 0 1 2 3 Feel spacey or unreal
Section 4 – Large Intestine (58)
116. 0 1 2 3 Anus itches
117. 0 1 2 3 Coated tongue
118. 0 1 2 3 Feel worse in moldy or musty place
119. 0 1 2 3 Taken antibiotic for a total accumulated time of
(0=never, 1= <1 2="<3" 3="" month="" months="">3
months)
120. 0 1 2 3 Fungus or yeast infections
121. 0 1 2 3 Ring worm, "jock itch", "athletes foot", nail fungus
122. 0 1 2 3 Yeast symptoms increase with sugar, starch or
alcohol
123. 0 1 2 3 Stools hard or difficult to pass
124. 0 1 History of parasites (0=no, 1=yes)
125. 0 1 2 3 Less than one bowel movement per day
126. 0 1 2 3 Stools have corners or edges, are flat or ribbon
shaped
127. 0 1 2 3 Stools are not well formed (loose)
128. 0 1 2 3 Irritable bowel or mucus colitis
129. 0 1 2 3 Blood in stool
130. 0 1 2 3 Mucus in stool
131. 0 1 2 3 Excessive foul smelling lower bowel gas
132. 0 1 2 3 Bad breath or strong body odors
133. 0 1 2 3 Painful to press along outer sides of thighs
(Iliotibial Band)
134. 0 1 2 3 Cramping in lower abdominal region
135. 0 1 2 3 Dark circles under eyes
Section 5 – Mineral Needs (75)
136. 0 1 History of carpal tunnel syndrome (0=no, 1=yes)
137. 0 1 History of lower right abdominal pains or
ileocecal valve problems (0=no, 1=yes)
138. 0 1 History of stress fracture (0=no, 1=yes)
139. 0 1 2 3 Bone loss (reduced density on bone scan)
140. 0 1 Are you shorter than you used to be? (0=no,
1=yes)
141. 0 1 2 3 Calf, foot or toe cramps at rest
142. 0 1 2 3 Cold sores, fever blisters or herpes lesions
143. 0 1 2 3 Frequent fevers
144. 0 1 2 3 Frequent skin rashes and/or hives
145. 0 1 Herniated disc (0=no, 1=yes)
146. 0 1 2 3 Excessively flexible joints, "double jointed"
147. 0 1 2 3 Joints pop or click
148. 0 1 2 3 Pain or swelling in joints
149. 0 1 2 3 Bursitis or tendonitis
150. 0 1 History of bone spurs (0=no, 1=yes)
151. 0 1 2 3 Morning stiffness
152. 0 1 2 3 Nausea with vomiting
153. 0 1 2 3 Crave chocolate
154. 0 1 2 3 Feet have a strong odor
155. 0 1 2 3 History of anemia
156. 0 1 2 3 Whites of eyes (sclera) blue tinted
157. 0 1 2 3 Hoarseness
158. 0 1 2 3 Difficulty swallowing
159. 0 1 2 3 Lump in throat
160. 0 1 2 3 Dry mouth, eyes and/or nose
161. 0 1 2 3 Gag easily
162. 0 1 2 3 White spots on fingernails
163. 0 1 2 3 Cuts heal slowly and/or scar easily
164. 0 1 2 3 Decreased sense of taste or smell
Section 6 – Essential Fatty Acids (22)
165. 0 1 Experience pain relief with aspirin (0=no, 1=yes)
166. 0 1 2 3 Crave fatty or greasy foods
167. 0 1 2 3 Low- or reduced-fat diet (0=never, 1=years ago,
2=within past year, 3=currently)
168. 0 1 2 3 Tension headaches at base of skull
169. 0 1 2 3 Headaches when out in the hot sun
170. 0 1 2 3 Sunburn easily or suffer sun poisoning
171. 0 1 2 3 Muscles easily fatigued
172. 0 1 2 3 Dry flaky skin or dandruff
Section 7 – Sugar Handling (39)
173. 0 1 2 3 Awaken a few hours after falling asleep, hard to
get back to sleep
174. 0 1 2 3 Crave sweets
175. 0 1 2 3 Binge or uncontrolled eating
176. 0 1 2 3 Excessive appetite
177. 0 1 2 3 Crave coffee or sugar in the afternoon
178. 0 1 2 3 Sleepy in afternoon
179. 0 1 2 3 Fatigue that is relieved by eating
180. 0 1 2 3 Headache if meals are skipped or delayed
181. 0 1 2 3 Irritable before meals
182. 0 1 2 3 Shaky if meals delayed
183. 0 1 2 3 Family members with diabetes (0=none, 1=1 or
2, 2=3 or 4, 3=more than 4)
184. 0 1 2 3 Frequent thirst
185. 0 1 2 3 Frequent urination
Section 8 – Vitamin Need (81)
186. 0 1 2 3 Muscles become easily fatigued
187. 0 1 2 3 Feel exhausted or sore after moderate exercise
188. 0 1 2 3 Vulnerable to insect bites
189. 0 1 2 3 Loss of muscle tone, heaviness in arms/legs
190. 0 1 2 3 Enlarged heart or congestive heart failure
191. 0 1 2 3 Pulse below 65 per minute (0=no, 1=yes)
192. 0 1 2 3 Ringing in the ears (Tinnitus)
193. 0 1 2 3 Numbness, tingling or itching in hands and feet
194. 0 1 2 3 Depressed
195. 0 1 2 3 Fear of impending doom
196. 0 1 2 3 Worrier, apprehensive, anxious
197. 0 1 2 3 Nervous or agitated
198. 0 1 2 3 Feelings of insecurity
199. 0 1 2 3 Heart races
200. 0 1 2 3 Can hear heart beat on pillow at night
201. 0 1 2 3 Whole body or limb jerk as falling asleep
202. 0 1 2 3 Night sweats
203. 0 1 2 3 Restless leg syndrome
204. 0 1 2 3 Cracks at corner of mouth (Cheilosis)
205. 0 1 2 3 Fragile skin, easily chaffed, as in shaving
206. 0 1 2 3 Polyps or warts
207. 0 1 2 3 MSG sensitivity
208. 0 1 2 3 Wake up without remembering dreams
209. 0 1 2 3 Small bumps on back of arms
210. 0 1 2 3 Strong light at night irritates eyes
211. 0 1 2 3 Nose bleeds and/or tend to bruise easily
212. 0 1 2 3 Bleeding gums especially when brushing teeth
Section 9 – Adrenal (78)
213. 0 1 2 3 Tend to be a "night person"
214. 0 1 2 3 Difficulty falling asleep
215. 0 1 2 3 Slow starter in the morning
216. 0 1 2 3 Tend to be keyed up, trouble calming down
217. 0 1 2 3 Blood pressure above 120/80
218. 0 1 2 3 Headache after exercising
219. 0 1 2 3 Feeling wired or jittery after drinking coffee
220. 0 1 2 3 Clench or grind teeth
221. 0 1 2 3 Calm on the outside, troubled on the inside
222. 0 1 2 3 Chronic low back pain, worse with fatigue
223. 0 1 2 3 Become dizzy when standing up suddenly
224. 0 1 2 3 Difficulty maintaining manipulative correction
225. 0 1 2 3 Pain after manipulative correction
226. 0 1 2 3 Arthritic tendencies
227. 0 1 2 3 Crave salty foods
228. 0 1 2 3 Salt foods before tasting
229. 0 1 2 3 Perspire easily
230. 0 1 2 3 Chronic fatigue, or get drowsy often
231. 0 1 2 3 Afternoon yawning
232. 0 1 2 3 Afternoon headache
233. 0 1 2 3 Asthma, wheezing or difficulty breathing
234. 0 1 2 3 Pain on the medial or inner side of the knee
235. 0 1 2 3 Tendency to sprain ankles or "shin splints"
236. 0 1 2 3 Tendency to need sunglasses
237. 0 1 2 3 Allergies and/or hives
238. 0 1 2 3 Weakness, dizziness
Section 10 – Pituitary (29)
239. 0 1 Height over 6' 6" (0=no, 1=yes)
240. 0 1 Early sexual development (before age 10) (0=no,
1=yes)
241. 0 1 2 3 Increased libido
242. 0 1 2 3 Splitting type headache
243. 0 1 2 3 Memory failing
244. 0 1 Tolerate sugar, feel fine when eating sugar
(0=no, 1=yes)
245. 0 1 Height under 4' 10" (0=no, 1=yes)
246. 0 1 2 3 Decreased libido
247. 0 1 2 3 Excessive thirst
248. 0 1 2 3 Weight gain around hips or waist
249. 0 1 2 3 Menstrual disorders
250. 0 1 Delayed sexual development (after age 13)
(0=no, 1=yes)
251. 0 1 2 3 Tendency to ulcers or colitis
Section 11 – Thyroid (48)
252. 0 1 2 3 Sensitive/allergic to iodine
253. 0 1 2 3 Difficulty gaining weight, even with large
appetite
254. 0 1 2 3 Nervous, emotional, can't work under pressure
255. 0 1 2 3 Inward trembling
256. 0 1 2 3 Flush easily
257. 0 1 2 3 Fast pulse at rest
258. 0 1 2 3 Intolerance to high temperatures
259. 0 1 2 3 Difficulty losing weight
260. 0 1 2 3 Mentally sluggish, reduced initiative
261. 0 1 2 3 Easily fatigued, sleepy during the day
262. 0 1 2 3 Sensitive to cold, poor circulation (cold hands
and feet)
263. 0 1 2 3 Constipation, chronic
264. 0 1 2 3 Excessive hair loss and/or coarse hair
265. 0 1 2 3 Morning headaches, wear off during the day
266. 0 1 2 3 Loss of lateral 1/3 of eyebrow
267. 0 1 2 3 Seasonal sadness
Section 12 – Men Only (27)
268. 0 1 2 3 Prostate problems
269. 0 1 2 3 Difficulty with urination, dribbling
270. 0 1 2 3 Difficult to start and stop urine stream
271. 0 1 2 3 Pain or burning with urination
272. 0 1 2 3 Waking to urinate at night
273. 0 1 2 3 Interruption of stream during urination
274. 0 1 2 3 Pain on inside of legs or heels
275. 0 1 2 3 Feeling of incomplete bowel evacuation
276. 0 1 2 3 Decreased sexual function
Section 13 – Women Only (60)
277. 0 1 2 3 Depression during periods
278. 0 1 2 3 Mood swings associated with periods (PMS)
279. 0 1 2 3 Crave chocolate around periods
280. 0 1 2 3 Breast tenderness associated with cycle
281. 0 1 2 3 Excessive menstrual flow
282. 0 1 2 3 Scanty blood flow during periods
283. 0 1 2 3 Occasional skipped periods
284. 0 1 2 3 Variations in menstrual cycles
285. 0 1 2 3 Endometriosis
286. 0 1 2 3 Uterine fibroids
287. 0 1 2 3 Breast fibroids, benign masses
288. 0 1 2 3 Painful intercourse (dysparenia)
289. 0 1 2 3 Vaginal discharge
290. 0 1 2 3 Vaginal dryness
291. 0 1 2 3 Vaginal itchiness
292. 0 1 2 3 Gain weight around hips, thighs and buttocks
293. 0 1 2 3 Excess facial or body hair
294. 0 1 2 3 Hot flashes
295. 0 1 2 3 Night sweats (in menopausal females)
296. 0 1 2 3 Thinning skin
Section 14 – Cardiovascular (30)
297. 0 1 2 3 Aware of heavy and/or irregular breathing
298. 0 1 2 3 Discomfort at high altitudes
299. 0 1 2 3 "Air hunger" or sigh frequently
300. 0 1 2 3 Compelled to open windows in a closed room
301. 0 1 2 3 Shortness of breath with moderate exertion
302. 0 1 2 3 Ankles swell, especially at end of day
303. 0 1 2 3 Cough at night
304. 0 1 2 3 Blush or face turns red for no reason
305. 0 1 2 3 Dull pain or tightness in chest and/or radiate
into right arm, worse with exertion
306. 0 1 2 3 Muscle cramps with exertion
Section 15 – Kidney and Bladder (13)
307. 0 1 2 3 Pain in mid-back region
308. 0 1 2 3 Puffy around the eyes, dark circles under eyes
309. 0 1 History of kidney stones (0=no, 1=yes)
310. 0 1 2 3 Cloudy, bloody or darkened urine
311. 0 1 2 3 Urine has a strong odor
Section 16 – Immune system (30)
312. 0 1 2 3 Runny or drippy nose
313. 0 1 2 3 Catch colds at the beginning of winter
314. 0 1 2 3 Mucus producing cough
315. 0 1 2 3 Frequent colds or flu (0=1 or less per year, 1=2
to 3 times per year, 2=4 to 5 times per year, 3=6
or more times per year)
316. 0 1 2 3 Other infections (sinus, ear, lung, skin, bladder,
kidney, etc.) (0=1 or less per year, 1=2 to 3
times per year, 2=4 to 5 times per year, 3=6 or
more times per year)
317. 0 1 2 3 Never get sick (0 = sick only 1 or 2 times in last
2 years, 1 = not sick in last 2 years, 2 = not
sick in last 4 years, 3 = not sick in last 7 years)
318. 0 1 2 3 Acne (adult)
319. 0 1 2 3 Itchy skin (Dermatitis)
320. 0 1 2 3 Cysts, boils, rashes
321. 0 1 2 3 History of Epstein Bar, Mono, Herpes,
Shingles, Chronic Fatigue Syndrome, Hepatitis
or other chronic viral condition (0 = no, 1 = yes
in the past, 2 = currently mild condition, 3 = severe)
Health Questionnaire (NTAF)
* Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.
Name: _____________________________________Age: ______ Sex: ________ Date:
SECTION A
• Is your memory noticeably declining?
• Are you having a hard time remembering names
and phone numbers?
• Is your ability to focus noticeably declining?
• Has it become harder for you to learn things?
• How often do you have a hard time remembering
your appointments?
• Is your temperament getting worse in general?
• Are you losing your attention span endurance?
• How often do you find yourself down or sad?
• How often do you fatigue when driving compared
to the past?
• How often do you fatigue when reading compared
to the past?
• How often do you walk into rooms and forget why?
• How often do you pick up your cell phone and forget why?
SECTION B
• How high is your stress level?
• How often do you feel that you have something that
must be done?
• Do you feel you never have time for yourself?
• How often do you feel you are not getting enough
sleep or rest?
• Do you find it difficult to get regular exercise?
• Do you feel uncared for by the people in your life?
• Do you feel you are not accomplishing your
life’s purpose?
• Is sharing your problems with someone difficult for you?
SECTION C
SECTION C1
• How often do you get irritable, shaky, or have
lightheadedness between meals?
• How often do you feel energized after eating?
• How often do you have difficulty eating large
meals in the morning?
• How often does your energy level drop in the afternoon?
• How often do you crave sugar and sweets in the afternoon?
• How often do you wake up in the middle of the night?
• How often do you have difficulty concentrating
before eating?
• How often do you depend on coffee to keep yourself going?
• How often do you feel agitated, easily upset, and nervous
between meals?
SECTION C2
• Do you get fatigued after meals?
• Do you crave sugar and sweets after meals?
• Do you feel you need stimulants such as coffee after meals?
• Do you have difficulty losing weight?
• How much larger is your waist girth compared to
your hip girth?
• How often do you urinate?
• Have your thirst and appetite been increased?
• Do you have weight gain when under stress?
• Do you have difficulty falling asleep?
SECTION 1 - S
• Are you losing your pleasure in hobbies and interests?
• How often do you feel overwhelmed with ideas to manage?
• How often do you have feelings of inner rage (anger)?
• How often do you have feelings of paranoia?
• How often do you feel sad or down for no reason?
• How often do you feel like you are not enjoying life?
• How often do you feel you lack artistic appreciation?
• How often do you feel depressed in overcast weather?
• How much are you losing your enthusiasm for
your favorite activities?
• How much are you losing enjoyment for
your favorite foods?
• How much are you losing your enjoyment of
friendships and relationships?
• How often do you have difficulty falling into
deep restful sleep?
• How often do you have feelings of dependency
on others?
• How often do you feel more susceptible to pain?
• How often do you have feelings of unprovoked anger?
• How much are you losing interest in life?
SECTION 2 - D
• How often do you have feelings of hopelessness?
• How often do you have self-destructive thoughts?
• How often do you have an inability to handle stress?
• How often do you have anger and aggression
while under stress?
• How often do you feel you are not rested even
after long hours of sleep?
• How often do you prefer to isolate yourself from others?
• How often do you have unexplained lack of
concern for family and friends?
• How easily are you distracted from your tasks?
• How often do you have an inability to finish tasks?
• How often do you feel the need to consume
caffeine to stay alert?
• How often do you feel your libido has been decreased?
• How often do you lose your temper for minor reasons?
• How often do you have feelings of worthlessness?
SECTION 3 - G
• How often do you feel anxious or panic for no reason?
• How often do you have feelings of dread or
impending doom?
• How often do you feel knots in your stomach?
• How often do you have feelings of being
overwhelmed for no reason?
• How often do you have feelings of guilt about
everyday decisions?
• How often does your mind feel restless?
• How difficult is it to turn your mind off when you
want to relax?
• How often do you have disorganized attention?
• How often do you worry about things you were
not worried about before?
• How often do you have feelings of inner tension
and inner excitability?
SECTION 4 - ACH
• Do you feel your visual memory (shapes &
images) is decreased?
• Do you feel your verbal memory is decreased?
• Do you have memory lapses?
• Has your creativity been decreased?
• Has your comprehension been diminished?
• Do you have difficulty calculating numbers?
• Do you have difficulty recognizing objects & faces?
• Do you feel like your opinion about yourself
has changed?
• Are you experiencing excessive urination?
• Are you experiencing slower mental response?
ideas to manage?
Do you have feelings of paranoia?
Symptom groups listed in this flyer are not intended to be used as a diagnosis of any disease condition.
For nutritional purposes only.
Medication History
Please circle any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
Atropine, Ipratopium, Scopolamine, Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan
Acetylcholinesterase Reactivators
Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine,
Vecuronium, Hemicholine
Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum,
Megadon, Serax , Restoril, Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien, Sonata, Lunesta, Imovane
Cholinesterase Inhibitors (irreversible)
Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine,
Carbamate Insecticidses
Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)
Dopamine Receptor Agonists
Mirapex, Sifrol, Requip
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol,
Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify
GABA Antagonist Competitive binder
Flumazenil
Monoamine Oxidase Inhibitor (MAOI)
Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid
Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)
Remeron, Zispin, Avanza, Norset, Remergil, Axit
Selective Serotonin Reuptake Inhibitor
Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil,
Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine
Selective Serotonin Reuptake Enhancers
Stablon, Coaxil, Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine
Tricylic Antidepresseants (TCAs)
Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil
New Patient Health History
Please be assured that all information on this form and anything discussed during your consultation will be
confidential unless you grant permission otherwise
Name:______________________First Appt date:___________
Address:___________________City:___State:____ Zip_________
Day phone:___________ Evening phone:______ Cell:__________________
Referred by:______________________ YourEmail______________________
Date of Birth:________Age_____Height______Weight_______
Overall Health: circle one Excellent Good Fair Poor
Primary Reason for consultation:________________________
Previous treatments for this problem:____________________
Other concerns or problems____________________________
Current medications or supplements: ( please list all using extra paper if needed)
How many times in your life (approx) have you taken a course of antibiotics?
____1-5 ____5-10 ____more than 10 When was last course of antibiotics (approx.)?____________________
Are you currently under care with any physician or other health care provider. Please give names, date of last visit
and any problems identified at that time:
List all major illnesses or surgeries, accidents or injuries w/ approximate dates:
Please mark any scars on the body diagram included in the packet
List any dental work (fillings, crowns, root canals, extractions, bridges, gum problems)
Are you currently experiencing any dental issues that you are aware of?
Do you drink alcohol? Y N. If yes, how often and typical amount:_____________________________
Have you ever smoked Y N. Do you currently smoke? Y N. How much/day?
Marital Status (circle one) Single Divorced Partnered Married Widowed
How is health of partner? Excellent Good Fair Poor
Number of children if any_____
Do you have any health concerns for your children? Please describe briefly:
Any family history of serious illness or chronic conditions?
Cancer Diabetes Heart Mental Illness Depression/ Anxiety Alcoholism or Substance Abuse Other (please
note)
Any household pets or animals?
Where have you traveled outside of country and when?
What toxic chemicals do you know you are exposed to? Please consider hair chemicals, household cleaning
products, building materials, new furnishings, occupation-related chemicals, lawn, garden and household, etc.
Do you have a regular exercise program? If yes what is it?
What level of stress are you typically under? Low Medium High
What do you do to relieve stress?
What is your occupation and do you enjoy it?
Describe your sleep: ___hard time falling asleep ___broken sleep (wake up but fall back to sleep)
___fall asleep but wake up and can't get back to sleep ___wake up exhausted and dragging in a.m.
Do you live with other people that affect your food habits? What other things affect your food habits?
How willing are you to make dietary changes to address your health concerns?
___a few changes ____moderate _____substantial
Client Summary Sheet Name____________________________________
Special testing notes: ________________________Age: ____
Allergies:
Medication &Contraindications
Weight
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
___/___/___ _____________
BMI
___/___/___ _____/______%
___/___/___ _____/______%
___/___/___ _____/______%
Weight Gain Pattern
T A L O P
Blood pressure
Date; BP
Medication ; Contraindications
Contract between Healthy Wealth Survival and
__________________________________ Print client name
The purpose of this contract is to serve as a memorandum of understanding for our work
together.
Here is what you can expect from me:
1. I am a consulting functional nutritionist; I am not a doctor. I do not diagnose illness or
prescribe medication. I am trained to think about how the body systems function, and to
understand health concerns in terms of overall function with a focus on the role of
nutrition. Function improves or degrades along a continuum and as it degrades, one
moves closer toward a diagnosable disease. However, long before a diagnosable
disease or condition happens, we can often identify nutritional deficiencies or other
things that are interfering with healthy functioning, and correct them. My role is to help
you understand how your body works and to look at your symptoms and health concerns
in the context of healthy functioning.
2. I believe in the body's ability to repair itself, if given the right ingredients (quality food, air,
water, and supplements from concentrated food, herbs, homeopathic remedies and
similar non-toxic agents). I believe that most health concerns and symptoms if caught
sooner rather than later can be addressed without the use of pharmaceutical medication,
which, while suppressing symptoms, usually interferes with the body's inherent ability to
self-repair. I do not judge your choice to use or not use pharmaceuticals, however I will
work with you to understand possible alternatives if you ask for that information. I will not
advise you to discontinue any medication that has been prescribed to you. I assume that
if you are choosing to work with me, you are open to learning how you can support your
body in this process of self-healing and I will do my best to share that knowledge with
you through dietary and life-style counseling and through helping you understand how
your body works.
3. I promise to keep our scheduled appointments and to be prepared, present, and ready to
give you the best attention I can.
Here is what I ask from you:
1. My expectation is that you will be open to what may be new ways of looking at your
health and healing, and that you are willing to accept as a goal, taking gradual but
consistent steps to improve your nutritional habits as needed to improve your health.
2. I reserve your appointment time for you, and no one else. Therefore, I respectfully
request that you give me at minimum 24 hours notice if you find it necessary to change your appointment time so that I may offer that spot to someone else. I do charge the
office visit fee for last minute cancellations with limited exceptions for true emergencies.
3. If we have agreed on certain supplements as part of your program, and you have any
concerns in between appointments about your supplements, I would like you to call me
and let me know your concerns rather than waiting until your next visit to have your
concerns addressed.
4. I ask you to agree to a schedule of visits so that we can work together over time to
improve your health and nutritional lifestyle.
5. I ask that if you are pleased with the care and the results you get from our work together
that you refer friends, family and co-workers to Nutrition Magician. Likewise if you have
concerns with your care, I hope you will discuss those with me so that we can find a
positive resolution.
Cost of Services
Initial Health Evaluation $200.00
includes Nutrition Response and Heart Rate Variability (HRV) Testing.
Visits 1-3 45-60 minutes $90
Follow-up Visit 20-25 minutes. $50
Extended Visit per ¼ hour $20.
Email Consultations per ¼ hour $20.
Dietary Consultation 30 / 60 min. $50. / $95.
HRV Testing and report $20.
Phone Consultations (visits 4 and beyond) $60
Center for Functional Nutrition Accepts Visa, Mastercard, Checks and Cash.
Referral Recognition
Our business grows when our clients share their good results with
friends, family, co-workers, and others they care about. We hope you
will support the growth of Healthy Wealth Survival as we support you in
your health. In acknowledgement of the compliment you pay us when
you refer, we gratefully offer you coupons good for products or
services when someone you refer becomes a client. Thank you!
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