These complete forms are available: email: kbranigan@seattlebalancedbody.com for a copy and to schedule an appointment to have them evaluated. The key to good health is knowing what changes to make and what to keep doing. Nutritional Assessment Questionnaire: Sample: Section 1 55points- (upper GI) 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 Food Journal - sample |
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