Assessment Part 2 Part 2/4 Symptoms Please tick any symptoms that you are CURRENTLY experiencing or fill in as much detail as possible where appropriate 2a Are you currently experiencing these symptoms? Tick any/all that you are experiencing High Blood PressureDiagnosed with high cholesterol levelsDiagnosed heart diseaseResting pulse over 80 beats per minuteExercise less than 20 minutes 3 X's per weekEasily out of breathChest pains on exersion Alcohol consumption: Female: more than one unit daily YesNo Male: more than one unit daily YesNo Do you smoke? YesNo How much do you smoke per day: Which oils, butter or spreads do you use in cooking? Do you eat nuts/seeds? State which How often do you eat oily fish in a week? none1 p/week2 p/week3 or more p/week 2b Nervous YesNo Upset YesNo Agitated YesNo AnxiousYesNo If you miss a meal, do you experience any of the following? Irritability / Mood swings YesNoNot sure Poor memory / Concentration YesNoNot sure Foggy thinking processes YesNoNot sure Fatigue or Weakness YesNoNot sure Headaches YesNoNot sure Heart palpitations YesNoNot sure Shakiness, jitteriness or tremors YesNoNot sure Cravings for sweets YesNoNot sure Cravings for stimulants YesNoNot sure Do you experience any of the following without being able to explain why? Excessive / frequent urination YesNo Excessive thirst or appetite YesNo Breath smelling sweet YesNo Unintended weight loss or excessive weight gain YesNo 2c Average hours of sleep at night: hrs Do you suffer any of the following? Fatigue and lethargy not relieved by sleep YesNo Difficulty getting up in the morning/poor sleep patterns YesNo Decreased productivity YesNo Irritable, less tolerant, aggressive YesNo Less able to handle stress YesNo Lack of interest in life YesNo Unexplained anxiety YesNo Feel more awake/alive in the evening YesNo Light headed or dizzy if you stand up quick YesNo Difficulty building muscle or gaining weight YesNo Excessive sweating YesNo Suspected or known food allergies/sensitivities YesNo Which foods you have become sensitive to or are known to be allergic to? 2D Do you regularly suffer with any of the following? Lethargy, fatigue or poor stamina YesNo Difficulty losing weight YesNo Prone to cold hands/feet YesNo Constipation YesNo Dry skin / coarse hair YesNo Excessive hair loss YesNo Outer third of eyebrow has thinned or been lost YesNo Depression or difficulty coping YesNo Decreased sweating YesNo Loss of libido or lack of interest in sex YesNo Infertility or multiple miscarriages YesNo Menstrual irregularities YesNo Females Only This section is to be filled by women only 2E Are you pregnant? YesNo If Yes, how many weeks of gestation?: weeks Are you trying to become pregnant: YesNo Any fertility problems? Please state: How are your periods?: Heavy periods YesNo Irregular periods YesNo Period pains (cramps) YesNo If you suffer with PMS, which of the following best describes your PMS: PMS – anxiety, irritability, tension, mood swings YesNo PMS – breast tenderness, bloating, fluid retention, weight gain YesNo PMS – Depression, crying, forgetfulness YesNo Are you: Peri-menopausalMenopausalPost-menopauseNone of the above Do you use the contraceptive pill or IUD? If so which: Are you taking HRT? If so for how long 2F Food Rarely eat organic foods DoDo not Wash fruits and vegetables before cooking/eating DoDo not Eat processed foods regularly: Canned foods Less than 2/week2-4 /week5 or more/week Processed meats such as ham, salami, luncheon meats, etc Less than 2/week2-4 /week5 or more/week Ready-made meals Less than 2/week2-4 /week5 or more/week white flour products Less than 2/week2-4 /week5 or more/week Prepacked foods that have an extensive food label Less than 2/week2-4 /week5 or more/week Please answer Yes or No: Live or work in a smoky environment YesNo Live or work near a busy road YesNo Live or work near an industrial plant YesNo Cycle as a hobby or to work YesNo Job involves working with chemicals YesNo Often use recreational drugs YesNo Drink unfiltered tap water YesNo More than 3 mercury dental fillings YesNo 2G Please answer Yes or No: Have a personal or family history of cancer YesNo Catch more than 2 colds per year YesNo Prone to frequent colds and infections YesNo Prone to cold sores YesNo Prone to swollen or bleeding gums YesNo Have a definite reaction in the presence of strong smelling chemicals (perfumes, cleaning products etc. cause sneezing, watery eyes, skin reactions etc.) YesNo Do you suffer from an inflammatory condition? YesNo Are your lymph glands swollen or sore YesNo Prone to thrush and or cystitis YesNo Have you recently taken antibiotics YesNo Do you have a history of taking antibiotics YesNo Do you have an auto-immune disease? YesNo If Yes to auto-immune disease, please state which here: 2H Please list foods or drinks you would find difficult to cut out of your diet: Do you have? Migraines YesNo Facial Puffiness YesNo Itchy or Watery Eyes YesNo Dark Circles Under Eyes YesNo Sinusitis YesNo Excessive Sneezing YesNo Constant Sore Throat YesNo Excessive Mucus Production YesNo Muscle Aches and Pains YesNo Fluctuating Fatigue YesNo Fluid Retention YesNo Difficulty Losing Weight YesNo Rapid Weight Fluctuations YesNo Binge or Compulsive Eating YesNo Food Cravings YesNo Itchy Skin YesNo Psoriasis YesNo Asthma YesNo Hayfever YesNo Eczema or Uticaria (Hives) YesNo 2I Do you have? Gastric Ulcers or Gastritis YesNo Black or Tarry Stool YesNo Stomach Pains YesNo Sour Taste in Mouth YesNo Fast Eater/Do Not Chew Food Properly YesNo An Over-Full Feeling Within Half an Hour of Eating YesNo Abdominal Bloating and Discomfort YesNo Less Than One Bowel Movement Daily YesNo Stools Hard/Difficult to Pass YesNo Excessive Flatulence YesNo Weak, Peeling, Split or Ridged Nails YesNo Indigestion and Reflux YesNo Intolerance to Alcohol YesNo Yellow Hue to the Skin or Eyes YesNo History of or Family History of Liver/Gall Bladder Disease YesNo Fatty Foods Cause Nausea YesNo Bitter Taste in Mouth YesNo Light / Clay Coloured Stool YesNo Alternating Constipation and Diarrhea (IBS) YesNo Indigestion 1-3 hours After Eating YesNo Eating Fruits Causes Bloating YesNo Itching Around Rectum YesNo History of Taking Anitbiotics and/or NSAIDs (non-steroidal anti-inflammatory drugs) YesNo Multiple Food Sensitivites YesNo Difficulty Gaining Weight YesNo Unexplained Muscle Aches YesNo [multistep "1-4-http://www.nutritionalessence.com/test/assessment-page3"]
