CALANNA Pharmacy

Nutricheck Questionnaire

Nutricheck evaluation for

Full Name:*

Phone:*

Email:*

Country:

Age Group*

Where would you like to collect your results?

KEY: 0 = Never 1 = Mild/Occasionally 2 = Moderate/Frequently 3 = Severely

Does your hair tend to fall or break easily?

Have you been on a strict weight loss diet in the last 2 years?*

Is your vision at dusk or at night time poorer now than before?*

Is the skin on the back of your arms rough, thickened or scaly?*

Do you suffer from flatulence?*

Do you suffer with abdominal bloating especially after eating? *

Do you have bad breath or a bad taste in your mouth especially on wakening?*

Do you suffer from frequent coughs or colds?*

Do you have chronic or recurrent sinus congestion or catarrh?*

Do you get sore red gums or gums that bleed easily on brushing you teeth?*

Do you find that you bruise easily?*

Do you suffer with excessive dental plaque and/or caries?*

Do you get muscle tenderness or weakness in your legs?*

Do you get a burning feeling in your tongue or lips?*

Do you get palpitations, racing heartbeat or irregular heartbeat? *

Do you get numbness or tingling sensations in your hands or feet?*

Is your tongue sensitive to hot drinks or sore?*

Do you get cracks or soreness in the corners of your mouth?*

Do you get soreness, burning or gritty feeling in your eyes? *

Are you sensitive to bright lights?*

Do you have a tendency to dandruff or excessively oily skin?*

Do you get a reddish colouration around your nose and ears?*

Do you drink more than 2 glasses of alcohol per day average?*

Do you have a tendency towards eczema or other skin rashes?*

Do you get dizzy or light headed on standing up?*

Do you get swollen feet or do your shoes feel tight when you are on your feet for a long time?*

Do you tend to get cold fingers or toes especially at night?*

Do your fingers joints or toes feel stiff or sore on awakening?*

Do you find you don't dream or dream infrequently?*

Do you find it difficult to remember your dreams?*

Do you crave sweet or sugary foods?*

Do you eat white bread, pasta, sugar or white rice almost daily?*

Do you sunburn easily?*

Do you react to Monosodium Glutamate (MSG) that is, do you react to Chinese food?*

Do you tend to be easily excited or irritated?*

Do you have trouble getting to sleep or suffer from restless sleep?*

Do you find that your ability to concentrate is impaired?*

Do you have trouble making decisions?*

Do you often feel stressed or under strain?*

Do you have a tendency to be moody or easily depressed?*

Do you tend to suffer from episodic anxiety or panic attacks?*

Do you feel tired on wakening in the morning?*

Do you frequently feel excessively tired or exhausted?*

Do you tend to get a dull ache in the small of the back?*

Do you suffer with burning sensations in the feet?*

Do you suffer from constipation?*

Do you find that your co-ordination has diminished?*

Do you get a low backache especially on getting up in the morning?*

Do you get an 'electric shock' type of sensation on bending your neck quickly?*

Has your memory deteriorated?*

Do you suffer from muscle twitching or cramping?*

Are you sensitive to loud sounds? *

Do you find that your food tends to be tasteless?*

Do you find that your cuts and sores tend to heal slowly?*

Do you have white spots or streaks in your fingernails?*

Do you have horizontal grooves on your fingernails?*

Are your nails brittle or breaking easily?*

Are your nails soft and papery?*

Do you have stretch marks on your hips, stomach or buttocks?*

Did you suffer from growing pains in the legs during your early teenage years?*

Did you suffer from acne during your adolescence?*

Did you suffer from acne after adolescence?*

Do you suffer from dry or flakey skin?*

Do your nails easily split or peel back?*

Do you get irritation or itching inside your ears?*

Does the skin on your face or upper chest feel dry or lumpy?*

Is your hair dull or lustreless?*

Is the skin on your heels thickened?*

Is the skin on your heels cracked and/or painful?*

Do you find that you cannot fully straighten the 4th and 5th fingers of your hand?*

Do you get pain or soreness in the muscles with walking?*

Is the skin of your feet or toes pale and cold?*

Are the nails of your toes thickened or deformed?*

Do you find that you tire easily?*

Do you get hungry between meals or at night? *

Do you wake after a few hours sleep?*

Do you feel scared for no obvious reason?*

Do you frequently worry about things?*

Do you have bouts of feeling insecure?*

Do your feelings fluctuate quickly?*

Do you tend to cry or feel like crying easily?*

Do you have bouts of unreasonable anger or behaviour? *

Do you tend to magnify insignificant events?*

Do you drink more than 2 cups of coffee or cola drinks per day?*

Do you crave candy, soft drinks or coffee between meals, or during the afternoon? *

Do you find yourself unable to perform well under pressure?*

Do you suffer from headaches?*

Do you feel sleepy during the day?*

Do you feel drowsy or sleepy after meals? *

Do you have periods of low energy?*

Do you have to push yourself to get things done? *

Do you eat when you are nervous or tired?*

Do you get stomach cramps or nervous stomach?*

Do you find that eating gives you relief from tiredness?*

Do you have suicidal thoughts or feelings? *

Do you have feeling of hopelessness? *

Do you get bad dreams, nightmares or restless sleep?*

Do you get irritable before meals?*

Do you get shaky inside when hungry or after meals?*

Do you feel faint or light headed if meals are delayed or missed? *

Do you get generalised muscle aches and pains?*

Do you suffer from pain in the neck and shoulder muscles? *

Do you get blurred vision especially if tired or hungry? *

Do you get short of breathe on exertion?*

Do you have a reduced sex drive?*

Do you sweat excessively?*

Do you find it difficult to maintain an ideal weight?*

Do you have an excessive thirst or frequent urination?*

Do you get sore aching eyes with extensive use?*

Do you tend to get episodes of fluid retention?*

Send for Evaluation

NOTE: Medical information provided for this nutritional assessment will be kept strictly confidential.
NB: The Nutricheck Questionnaire should only be used during a professional health consultation. It should not be used as a prescription for self-medication of nutritional supplements. It does not guarantee that the patient will necessarily benefit from such supplementation. All parties involved in the development of Nutricheck only recommend the use of this product to identify nutritional problems and requirements in conjunction with a consultation with a professional health practitioner.

Nutricheck Questionnaire is a free Nutritional Assessment Questionnaire to assist our Practitioners in better diagnosing:

Mineral and Vitamin deficiencies
Allergies
Sugar Metabolism Health
Digestive Health
Bowel Flora Status

The results of the Nutricheck Questionnaire are represented in graph form. You will receive a phone call or email when the results are ready to arrange a time for a short consultation. We can do it over the phone but it is worth seeing your results and discussing them with one of our consultants.