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Nutricheck Questionnaire


Nutricheck evaluation for
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?*