Nutrition form 2

Form 2 of 2 - NSP form

If any of the following symptoms or activities have occured within the past three months, please indicate by writing 1 - for mild or rarely occurring
2 - for moderate or regularly occcuring
3 - for severe or often occuring, or leave blank if the symptom/statement does not apply.

part 1

* Indicates required field

Name *

First

Last

1. General fatigue or weakness *

2. Difficulty losing weight *

3. Frequent illness/infections *

4. High stress lifestyle *

5. Smoking *

6. Drinking more than 2 cups of coffee/day *

7. Bad breath and/or body odour *

8. constipation *

9. bags under eyes *

10. crave sugars, bread, alcohol *

11. difficulty digesting certain foods *

12. Have used antibiotics in the last 10 years *

13. allergies *

14. poor concentration or memory *

15. belching or burping after meals *

16. skin/complexion problems *

17. Frequent consumption of red meat *

18. Regular use of dairy products *

19. heavy alcohol consumption *

20. exposure to toxins/chemicals *

21. frequent mood swings *

22. depressed and/or irritable *

23. brittle fingernails *

24. dry, brittle hair, split ends *

25. high fat/high cholesterol diet *

26. nervousness/anxiety/tension/worry *

27. insomnia/restlesss sleep *

28. low fibre diet *

29. muscle cramps *

30. sleepy when sitting up *

31. menstral cramps *

32. bronchitis/asthma/pneumonia/emphysema *

33. cellulite *

34. Cold hands and feet *

35. varicose veins *

36. feeling out of control *

37. Food/chemical sensitivities *

38. Frequent yeast/fungus problems *

39. Bones break easily/osteoporosis *

40. Too little exercise *

41. excessive mucus *

42. short of breath climbing stairs *

43. tingling in lips, fingers, arms, legs *

44. chest pains *

45. very rapid or slow heart beat *

46. painful, hard or thin bowel movements *

47. alternating constipation/diarrhea *

48. recurrent bladder infections *

49. menopause/hot flashes *

50. PMS *

51. difficult urination *

52. swollen glands/puffy throat *

53. lower abdominal pain *

54. frequent need to. urinate *

55. joint pain *

56. sinus inflammation/discharge *

57. arthritis *

58. sudden weight gain or loss *

59. headaches/migraines *

60. taking birth control pills *

61. lower back pain *

62. dry, flaky skin *

63. drink less than 6 glasses of fluids/day *

64. water retention *

65. low sex drive *

66. feeling heavy/bloated after meals *

67. chronic cough *

part 2 - the digestive system

Complete the following section with the same 1, 2, 3 rating system as above.

underactive stomach

excessive gas, belching or burping after meals *

stomach bloated after eating *

sleepiy after eating *

longitudinal striations on fingernails *

eating when rushed/in a hurry *

halitosis *

full feeling after heavy meat meal *

heavy, tired feeling after eating *

nausea after taking supplements *

acne *

undigested food in the stool *

overactive stomach

stomach pain 1 hour after eating or at night *

burning sensation in stomach *

pain aggravated by worry/tension *

hiatal hernia *

gastritis, gastric ulcer *

nausea, vomiting *

sensation of acidity in abdominal area *

heartburn, indigestion *

blood in stool *

lower back pain *

long term aspirin use *

liver

yellow or pale fingernails *

skin oily on nose and forehead *

fats/greasy foods cause nausea/headache *

vertical white streaks on fingernails *

onions, cabbage, radishes, cucumbers cause bloating/gas *

bad breath/bad taste in mouth *

excess body odour *

high cholesterol/high cholesterol diet *

migraine headaches *

discomfort underneath right ribcage *

food allergies *

irritable, easily angered *

weight gain around the abdomen *

yellow palms *

poor concentration *

difficulty losing weight *

acne, boils, rashes, psoriasis or eczema *

constipation *

gall bladder

gallstones/history of gallstones *

stool appears clay coloured, foul odoured *

constipation *

high cholesterol diet; high blood cholesterol levels *

severe pain in right upper abdomen *

pancreas

severe abdominal pain *

nausea and vomiting *

slow digestion; feel full for hours after eating *

fever *

alcohol addiction *

jaundice *

dysglycemia

hungry up to 3 hours after eating *

strong, sudden cravings for sweets, starches, coffee or alcohol *

frequent "midnight snacks" *

nervous/anxious feelings relieved by eating *

irritable if late for or skkip a meal *

overweight *

addicted to coffee with sugar and/or colas *

family history of diabetes *

fatigue *

frequent headaches *

fainting spells *

depression *

lose temper easily *

Part 3: The Intestinal System

Candidiasis

Extreme fatigue *

recurrent vaginal infections *

frequent use of antibiotics *

white coated tongue, oral thrush *

crave sugars, bread, alcohol *

headaches *

tonsillitis, recurrent strep throat *

itchy, watery or dry eyes *

skin flushes *

chronic indigestion, frequently use antacids *

always cold, especially in extremeties *

pms *

pain in pelivc area *

abdominal gas and bloating *

loss of sex drive *

cystitis, repeated bladder infection *

increasing food and chemical sensitivities, severe reaction to *

endometriosis/ovary problems *

chronic diarrhea *

hives, psoriasis, acne, skin rashes *

rectal itching *

abnormal muscle aches from exercise *

excessive wax in ears *

unepected/unexplained weight gain *

impotence *

canker sores *

athletes foot, finger/toenail fungus, ringworm *

jock itch *

brain fog *

irritability *

memory loss *

mental confusion *

depression or anger for no reason *

anxiety, panic attacks *

inability to concentrate *

phobic/compulsive *

lethargy *

mood swings *

itchy ears, nose, anus *

Parasites

forgetfulness *

slow reflexes *

gas and bloating *

unclear thinking *

loss of appetite *

yellowish or pale face *

fast heartbeat *

heart pain *

pain in navel *

eating more than normal but still feeling hungry *

blurry or unclear vision *

pain in the back, thighs, shoulders *

numb hands *

drooling while sleeping *

damp lips at night *

dry lips during the day *

grind teeth while asleep *

bedwetting *

lethargy; chronic fatigue *

dark circles under eyes *

cancer *

Part 5: The Lymphatic System

Thymus (immunity)

excessive sleep *

very susceptible to infections *

swollen glands/tonsils/throat/armpits *

history of cancer, ms, parkinsons, arthritis *

loss of appetite *

headaches *

soreness on both sides of neck at shoulder *

feel puffiness in throat *

look older than chronological age *

flu-like symptoms often occur *

lupus *

Allergies

Acne, psoriasis, dermatitis, eczema *

Rapid pulse, heart irregularities *

Frequent headaches *

Hay fever *

Frequent cravings for certain foods *

Periods of blurred vision *

Repeated ear trouble *

Hyperactivity *

Dizzy spells *

Periods of confusion *

Poor concentration *

Epilepsy *

Muscle cramps or spasms *

Abornmal body odour *

Excessive sweating, night sweats *

Bowel disease, IBS, IBD, Crohn's, etc. *

Joint pains or stiffness *

Frequent night urination *

Wheezing *

Pale face *

Hives *

Nose runs constantly *

Noticeable changes in writing throughout day *

Nosebleeds *

Bloating or gas after eating certain foods *

Canker sores *

Dark circles under eyes *

Stuffy nose *

The Glandular/Endocrine System

Underactive thyroid/hypothyroid

Distinct, lethargic tiredness or sluggishness *

Cold hands or feet *

Mercury amalgams (fillings) *

Gain weight easily, fail to lose on diets *

Constipation, less than one bowel movement a day *

Low energy in the morning *

Low pulse rate *

Low body temperature, especially bed rest *

Hair dry, brittle, dull, lifeless *

Flaky, dry rough skin *

Feel stiff after sitting still for some time *

Mood swings *

Unusually square and wide fingernails *

High cholesterol *

Diminished sex drive *

Pituitary

Headaches affecting one side of head *

Females: loss of menstrual function *

Moody *

Overweight from waist down *

Overweight from waist up *

Excessive urination *

Pain in little finger of left hand *

Swelling in ankles, fingers and/or feet *

Cold hands or feet *

Pain in left side of upper neck *

Overactive thyroid/hyperthyroid

Losing weight without trying *

Heart races while at rest *

Hands shake or tremble *

Protruding tongue *

Heart palpitations *

Nervous behaviour/hyperactivity *

Insomnia *

Increased appetite *

Frequent bowel movements, diarrhea *

Excessive sweating without exercising *

Adrenals

Stress or emotional upsets cause exhaustion *

Blood pressure decreases when going from a lying position to a sitting position *

Perspire excessively *

Neck and/or shoulder tension *

Frequent headaches *

Bow lines (depressed furrows) on fingernails *

Occasional cold sweats *

Tightness or lump in throat, especially when emotionally disturbed *

High or low blood pressure *

Rapid pulse *

Short temper *

Puffy face *

Skeletal

Pain, swelling, stiffness in joints *

Joint inflammation (rheumatoid arthritis) *

Pain, stiffness, inflammation of spine *

Facial pain *

Joints make popping sounds *

Gout *

Ankylosing spondylitis *

Bones fracture easily *

Gradual loss of height *

Tooth loss; teeth "falling out" *

Lack of exercise *

Rounding of shoulders; stooping *

Females: Menopause *

Pain in forearm or biceps *

Cramps in calf muscle during sleep or exercise *

Painful cramping of feet or toes *

Teeth prone to decay, frequent toothaches *

Malformation of bones *

Insomnia *

Muscles weak, weak grip, light objects feel heavy *

Heart palpitations *

Diet high in animal foods (meat, dairy, eggs) *

Muscular

Muscle pain *

Muscle weakness *

Sprains; muscle strains *

Muscle(s) spasm *

Neuromuscular

Muscles wasting in some part of the body *

Numbness or loss of sensation *

Mood swings and/or depression *

Blurred or double vision *

Tingling and/or numbness, especially in extremities *

Muscular stiffness *

Difficulty breathing *

Males: Impotence *

Tremors *

Loss of peripheral vision *

Slurred speech *

Objects fall from hands, reach in wrong place *

Hands tremble *

Impaired speech *

Submit 2 of 2

We Would Love to Have You Visit Soon
Open 24/7

SELKIRK, MANITOBA
Staffed Hours
Tuesdays 5:30 - 8:30 p.m.
Wednesdays 5:30 - 8:30 p.m.
Thursdays 5:30 - 8:30 p.m.
Saturdays 9 a.m. - 12 p..m.
Unstaffed at the front desk on long weekends and holidays
OPEN 24/7 FOR MEMBERS
privacy policy

Located in selkirk, manitoba

217 Clandeboye Avenue

​Form 2 of 2 - NSP form