Nutritional Questionnaire

 For each symptom that you experience often, score 1 point. If you experience any of the symptoms in bold type, score 2 points.

VITAMIN A

(   ) Mouth ulcers

(   ) Poor night vision

(   ) Acne

(   ) Frequent colds or infections

(   ) Dry flaky skin

(   ) Dandruff

(   ) Thrush or cystitis

(   ) Diarrhea

YOUR SCORE

 

VITAMIN D

(   ) Arthritis or osteoporosis

(   ) Backache

(   ) Tooth decay

(   ) Hair loss

(   ) Muscle twitching or spasms

(   ) Joint pain or stiffness

(   ) Weak bones

YOUR SCORE

 

VITAMIN E

(   ) Lack of sex drive

(   ) Exhaustion after light exercise

(   ) Easy bruising

(   ) Slow wound healing

(   ) Varicose veins

(   ) Poor skin elasticity

(   ) Loss of muscle tone

(   ) Infertility

YOUR SCORE

 

VITAMIN C

(   ) Frequent colds

(   ) Lack of energy

(   ) Frequent infections

(   ) Bleeding or tender gums

(   ) Easy bruising

(   ) Nose bleeds

(   ) Slow wound healing

(   ) Red pimples on skin

YOUR SCORE

 

VITAMIN B1

(   ) Tender muscles

(   ) Eye pains

(   ) Irritability

(   ) Poor concentration

(   ) "Prickly" legs

(   ) Poor memory

(   ) Stomach pains

(   ) Constipation

(   ) Tingling hands

(   ) Rapid heartbeat

YOUR SCORE

 

VITAMIN B2

(   ) Bloodshot, burning, or gritty eyes

(   ) Sensitivity to bright lights

(   ) Sore tongue

(   ) Cataracts

(   ) Dull or oily hair

(   ) Eczema or dermatitis

(   ) Split nails

(   ) Cracked lips

YOUR SCORE

 

VITAMIN B3 (NIACIN)

(   ) Lack of energy

(   ) Diarrhea

(   ) Insomnia

(   ) Headaches or migraines

(   ) Poor memory

(   ) Anxiety or tension

(   ) Depression

(   ) Irritability

YOUR SCORE

 

VITAMIN B5

(   ) Muscle tremors, ramps, or spasm

(   ) Apathy

(   ) Poor concentration

(   ) Burning feet or tender heels

(   ) Nausea or vomiting

(   ) Lack of energy

(   ) Exhaustion after light exercise

(   ) Anxiety or tension

(   ) Teeth grinding

YOUR SCORE

 

MAGNESIUM

(   ) Muscle cramps, tremors, or spasms

(   ) Muscle weakness

(   ) Insomnia, nervousness, or hyperactivity

(   ) High blood pressure

(   ) Irregular or rapid heartbeat

(   ) Constipation

(   ) Fits or convulsions

(   ) Breast tenderness or water retention

(   ) Depression or confusion

YOUR SCORE

 

ZINC

(   ) Decline in sense of taste or smell

(   ) White marks on more than two finger nails

(   ) Frequent infections

(   ) Stretch marks

(   ) Acne or greasy skin

YOUR SCORE

 

MANGANESE

(   ) Muscle twitches

(   ) Childhood "growing pains"

(   ) Dizziness or poor sense of balance

(   ) Fits or convulsions

(   ) Sore knees

YOUR SCORE

  

SELENIUM

(   ) Family history of cancer

(   ) Signs of premature aging

(   ) Cataracts

(   ) High blood pressure

YOUR SCORE

 

CHROMIUM

(   ) Excessive or cold sweats

(   ) Dizziness or irritability after six hours without food

(   ) Need for frequent meals

(   ) Cold hands

(   ) Need for excessive sleep or drowsiness during the day

YOUR SCORE