PARTI Readthefollowingquestionsandcirclethenumberthatapplies

NutritionalAssessmentQuestionnaire1.5

Name: / _ / _ / Date: / / / /
BirthDate:_ / Gender: / _

Pleaselistyourfivemajorhealthconcerns inorderofimportance:

Notes:

PARTI Readthefollowingquestionsandcirclethenumberthatapplies:

KEY: 0 = Donotconsume oruse

1 = Consumeoruse2 to3timesmonthly

2 = Consumeoruseweekly

3 = Consumeorusedaily

DIET 58

1. / 0 / 1 / 2 / 3 / Alcohol / 7. / 0 / 1 / 2 / 3 / Cigars/pipes / 14. / 0 / 1 / Radiationexposure(0=no,1=yes)
2. / 0 / 1 / 2 / 3 / Artificialsweeteners / 8. / 0 / 1 / 2 / 3 / Caffeinatedbeverages / 15. / 0 / 1 / 2 / 3 / Refinedflour/bakedgoods
3. / 0 / 1 / 2 / 3 / Candy,desserts,refined / 9. / 0 / 1 / 2 / 3 / Fast foods / 16. / 0 / 1 / 2 / 3 / Vitaminsandminerals
sugar / 10. / 0 / 1 / 2 / 3 / Friedfoods / 17. / 0 / 1 / 2 / 3 / Water,distilled
4. / 0 / 1 / 2 / 3 / Carbonatedbeverages / 11. / 0 / 1 / 2 / 3 / Luncheonmeats / 18. / 0 / 1 / 2 / 3 / Water,tap
5. / 0 / 1 / 2 / 3 / Chewingtobacco / 12. / 0 / 1 / 2 / 3 / Margarine / 19. / 0 / 1 / 2 / 3 / Water, well
6. / 0 / 1 / 2 / 3 / Cigarettes / 13. / 0 / 1 / 2 / 3 / Milkproducts / 20. / 0 / 1 / 2 / 3 / Dietoften forweightcontrol

LIFESTYLE 12

21.0 / 1 / 2 / 3 / Exerciseperweek (0= 2ormoretimesa week,1 = 1timeaweek,2 = 1or2timesa month,3 =never,lessthan oncea
month)
22.0 / 1 / 2 / 3 / Changedjobs(0= over12monthsago,1 = withinlast12 months,2 = withinlast6months,3 = withinlast2months)
23.0 / 1 / 2 / 3 / Divorced(0= never,over2 years ago,1= withinlast2 years,2 = withinlast year,3 = withinlast6months)
24.0 / 1 / 2 / 3 / Workover60hours/week(0=never,1 =occasionally,2 = usually,3= always)

MEDICATIONS Indicateanymedicationsyou’recurrentlytakingorhavetakeninthelastmonth(0=no,1=yes): 54

PARTII(Seekeyatbottom ofpage)

Section 1– UpperGastrointestinalSystem 55

52. / 0 / 1 / 2 / 3 / Belchingorgaswithinonehouraftereating / 61. / 0 / 1 / 2 / 3 / Feellikeskippingbreakfast
53. / 0 / 1 / 2 / 3 / Heartburnoracidreflux / 62. / 0 / 1 / 2 / 3 / Feelbetterifyoudon’t eat
54. / 0 / 1 / 2 / 3 / Bloatingwithinonehouraftereating / 63. / 0 / 1 / 2 / 3 / Sleepyaftermeals
55. / 0 / 1 / Vegandiet(nodairy,meat,fishoreggs)(0=no, / 64. / 0 / 1 / 2 / 3 / Fingernailschip, peelorbreakeasily
1=yes) / 65. / 0 / 1 / 2 / 3 / Anemiaunresponsivetoiron
56. / 0 / 1 / 2 / 3 / Badbreath(halitosis) / 66. / 0 / 1 / 2 / 3 / Stomachpainsorcramps
57. / 0 / 1 / 2 / 3 / Lossof tasteformeat / 67. / 0 / 1 / 2 / 3 / Diarrhea,chronic
58. / 0 / 1 / 2 / 3 / Sweathasastrongodor / 68. / 0 / 1 / 2 / 3 / Diarrheashortlyaftermeals
59. / 0 / 1 / 2 / 3 / Stomachupsetbytakingvitamins / 69. / 0 / 1 / 2 / 3 / Blackortarrycoloredstools
60. / 0 / 1 / 2 / 3 / Senseof excessfullnessaftermeals / 70. / 0 / 1 / 2 / 3 / Undigestedfoodinstool

KEY: 0=No,symptomdoesnotoccur

1=Yes,minorormildsymptom,rarelyoccurs(monthly)

2=Moderatesymptom,occursoccasionally(weekly)

3=Severesymptom,occursfrequently(daily)

Section 2–LiverandGallbladder 68

71. / 0 / 1 / 2 / 3 / Painbetweenshoulderblades / 85. / 0 / 1 / Easilyhungoverifyouweretodrinkwine(0=no,
72. / 0 / 1 / 2 / 3 / Stomachupsetbygreasyfoods / 1=yes)
73. / 0 / 1 / 2 / 3 / Greasyor shinystools / 86. / 0 / 1 / 2 / 3 / Alcoholperweek(0=<3,1=<7,2 =<14,3=>14)
74. / 0 / 1 / 2 / 3 / Nausea / 87. / 0 / 1 / Recoveringalcoholic(0=no,1=yes)
75. / 0 / 1 / 2 / 3 / Sea,car, airplaneor motionsickness / 88. / 0 / 1 / Historyofdrugoralcoholabuse(0=no,1=yes)
76. / 0 / 1 / Historyofmorningsickness(0= no,1 = yes) / 89. / 0 / 1 / Historyofhepatitis(0=no,1=yes)
77. / 0 / 1 / 2 / 3 / Lightor claycoloredstools / 90. / 0 / 1 / Longtermuseofprescription/recreationaldrugs
78. / 0 / 1 / 2 / 3 / Dryskin,itchyfeetor skinpeelsonfeet / (0=no,1=yes)
79. / 0 / 1 / 2 / 3 / Headacheovereyes / 91. / 0 / 1 / 2 / 3 / Sensitivetochemicals(perfume,cleaning
80. / 0 / 1 / 2 / 3 / Gallbladderattacks(0=never,1=yearsago,
2=withinlast year,3=withinpast3months) / 92. / 0 / 1 / 2 / 3 / agents,etc.)
Sensitivetotobaccosmoke
81. / 0 / 1 / Gallbladderremoved(0=no,1=yes) / 93. / 0 / 1 / 2 / 3 / Exposureto dieselfumes
82. / 0 / 1 / 2 / 3 / Bitter tasteinmouth,especiallyaftermeals / 94. / 0 / 1 / 2 / 3 / Painunderrightside of ribcage
83. / 0 / 1 / Becomesickif youwereto drinkwine(0=no, / 95. / 0 / 1 / 2 / 3 / Hemorrhoidsor varicoseveins
1=yes) / 96. / 0 / 1 / 2 / 3 / Nutrasweet(aspartame)consumption
84. / 0 / 1 / Easilyintoxicatedifyouwereto drinkwine / 97. / 0 / 1 / 2 / 3 / Sensitiveto Nutrasweet(aspartame)
(0=no,1=yes) / 98. / 0 / 1 / 2 / 3 / ChronicfatigueorFibromyalgia
Section 3– SmallIntestine 47
99. / 0 1 / 2 / 3 / Foodallergies / 108. / 0 / 1 / 2 / 3 / Crohn'sdisease(0=no,1=yesin thepast,
100. / 0 1 / 2 / 3 / Abdominalbloating1to2 hoursaftereating / 2=currentlymildcondition,3=severe)
101. / 0 1 / Specificfoodsmakeyou tiredorbloated(0=no, / 109. / 0 / 1 / 2 / 3 / Wheatorgrainsensitivity
1=yes) / 110. / 0 / 1 / 2 / 3 / Dairysensitivity
102. / 0 1 / 2 / 3 / Pulsespeedsaftereating / 111. / 0 / 1 / Aretherefoodsyoucouldnotgiveup(0=no,
103. / 0 1 / 2 / 3 / Airborneallergies / 1=yes)
104. / 0 1 / 2 / 3 / Experiencehives / 112. / 0 / 1 / 2 / 3 / Asthma,sinus infections,stuffynose
105. / 0 1 / 2 / 3 / Sinuscongestion,"stuffyhead" / 113. / 0 / 1 / 2 / 3 / Bizarrevividdreams,nightmares
106. / 0 1 / 2 / 3 / Cravebreadornoodles / 114. / 0 / 1 / 2 / 3 / Useover-the-counterpainmedications
107. / 0 1 / 2 / 3 / Alternatingconstipationanddiarrhea / 115. / 0 / 1 / 2 / 3 / Feelspaceyorunreal
Section 4–LargeIntestine 58
116. / 0 / 1 / 2 3 / Anusitches / 126. / 0 / 1 / 2 / 3 / Stoolshavecornersoredges,areflat orribbon
117. / 0 / 1 / 2 3 / Coatedtongue / shaped
118. / 0 / 1 / 2 3 / Feel worseinmoldyormustyplace / 127. / 0 / 1 / 2 / 3 / Stoolsarenotwell formed(loose)
119. / 0 / 1 / 2 3 / Takenantibioticfora totalaccumulatedtime of / 128. / 0 / 1 / 2 / 3 / Irritablebowelor mucuscolitis
(0=never,1=1month,2=3months,3=3 / 129. / 0 / 1 / 2 / 3 / Bloodinstool
months) / 130. / 0 / 1 / 2 / 3 / Mucusinstool
120. / 0 / 1 / 2 3 / Fungusor yeastinfections / 131. / 0 / 1 / 2 / 3 / Excessivefoul smellinglowerbowelgas
121. / 0 / 1 / 2 3 / Ring worm,"jockitch", "athletesfoot",nailfungus / 132. / 0 / 1 / 2 / 3 / Badbreathorstrongbodyodors
122.
123. / 0
0 / 1
1 / 2 3
2 3 / Yeastsymptomsincreasewithsugar,starchor
alcohol
Stoolshardordifficulttopass / 133.
134. / 0
0 / 1
1 / 2
2 / 3
3 / Painfultopress alongoutersidesof thighs
(IliotibialBand)
Crampingin lowerabdominalregion
124. / 0 / 1 / Historyofparasites(0=no,1=yes) / 135. / 0 / 1 / 2 / 3 / Darkcirclesundereyes
125. / 0 / 1 / 2 3 / Lessthanonebowelmovementperday
Section 5– MineralNeeds 75
136. / 0 / 1 / Historyofcarpaltunnelsyndrome(0=no,1=yes) / 150. / 0 / 1 / Historyofbonespurs (0=no,1=yes)
137. / 0 / 1 / Historyoflowerrightabdominalpainsor / 151. / 0 / 1 / 2 / 3 / Morningstiffness
ileocecalvalveproblems(0=no,1=yes) / 152. / 0 / 1 / 2 / 3 / Nauseawithvomiting
138. / 0 / 1 / Historyofstressfracture(0=no,1=yes) / 153. / 0 / 1 / 2 / 3 / Cravechocolate
139. / 0 / 1 / 2 3 / Boneloss(reduceddensityonbonescan) / 154. / 0 / 1 / 2 / 3 / Feet haveastrongodor
140. / 0 / 1 / Areyoushorterthanyou usedto be?(0=no, / 155. / 0 / 1 / 2 / 3 / Historyofanemia
1=yes) / 156. / 0 / 1 / 2 / 3 / Whitesofeyes (sclera)bluetinted
141. / 0 / 1 / 2 3 / Calf,footortoecrampsat rest / 157. / 0 / 1 / 2 / 3 / Hoarseness
142. / 0 / 1 / 2 3 / Coldsores,feverblistersorherpeslesions / 158. / 0 / 1 / 2 / 3 / Difficultyswallowing
143. / 0 / 1 / 2 3 / Frequentfevers / 159. / 0 / 1 / 2 / 3 / Lumpin throat
144. / 0 / 1 / 2 3 / Frequentskinrashesand/orhives / 160. / 0 / 1 / 2 / 3 / Drymouth,eyes and/ornose
145. / 0 / 1 / Herniateddisc(0=no,1=yes) / 161. / 0 / 1 / 2 / 3 / Gageasily
146. / 0 / 1 / 2 3 / Excessivelyflexiblejoints,"doublejointed" / 162. / 0 / 1 / 2 / 3 / Whitespotsonfingernails
147. / 0 / 1 / 2 3 / Jointspopor click / 163. / 0 / 1 / 2 / 3 / Cutshealslowlyand/orscar easily
148. / 0 / 1 / 2 3 / Painorswellinginjoints / 164. / 0 / 1 / 2 / 3 / Decreasedsenseof tasteorsmell
149. / 0 / 1 / 2 3 / Bursitisortendonitis

KEY: 0=No,symptomdoesnotoccur

1=Yes,minorormildsymptom,rarelyoccurs(monthly)

2=Moderatesymptom,occursoccasionally(weekly)

3=Severesymptom,occursfrequently(daily)

Section 6– Essential FattyAcids 22

165. / 0 / 1 / Experiencepain reliefwithaspirin(0=no,1=yes) / 169. / 0 / 1 / 2 / 3 / Headacheswhenoutin thehotsun
166. / 0 / 1 / 2 / 3 Cravefattyorgreasyfoods / 170. / 0 / 1 / 2 / 3 / Sunburneasilyorsuffersunpoisoning
167. / 0 / 1 / 2 / 3 Low-orreduced-fatdiet(0=never,1=yearsago, / 171. / 0 / 1 / 2 / 3 / Muscleseasilyfatigued
168. / 0 / 1 / 2 / 2=withinpastyear,3=currently)
3 Tensionheadachesat baseofskull / 172. / 0 / 1 / 2 / 3 / Dryflakyskinordandruff
Section 7– SugarHandling 39
173. / 0 / 1 / 2 / 3 / Awakena fewhoursafterfallingasleep,hardto / 180. / 0 / 1 / 2 / 3 / Headacheifmealsareskippedordelayed
getbacktosleep / 181. / 0 / 1 / 2 / 3 / Irritablebeforemeals
174. / 0 / 1 / 2 / 3 / Cravesweets / 182. / 0 / 1 / 2 / 3 / Shakyifmealsdelayed
175. / 0 / 1 / 2 / 3 / Bingeoruncontrolledeating / 183. / 0 / 1 / 2 / 3 / Familymemberswithdiabetes(0=none,1=1or
176. / 0 / 1 / 2 / 3 / Excessiveappetite / 2, 2=3or4,3=morethan4)
177. / 0 / 1 / 2 / 3 / Cravecoffeeorsugarin theafternoon / 184. / 0 / 1 / 2 / 3 / Frequentthirst
178. / 0 / 1 / 2 / 3 / Sleepyinafternoon / 185. / 0 / 1 / 2 / 3 / Frequenturination
179. / 0 / 1 / 2 / 3 / Fatiguethatisrelievedbyeating
Section 8–VitaminNeed 81
186. / 0 / 1 / 2 / 3 / Musclesbecomeeasilyfatigued / 200. / 0 / 1 / 2 / 3 / Canhearheartbeat onpillowat night
187. / 0 / 1 / 2 / 3 / Feelexhaustedor soreaftermoderateexercise / 201. / 0 / 1 / 2 / 3 / Wholebodyorlimbjerkasfallingasleep
188. / 0 / 1 / 2 / 3 / Vulnerableto insectbites / 202. / 0 / 1 / 2 / 3 / Nightsweats
189. / 0 / 1 / 2 / 3 / Lossofmuscletone,heavinessinarms/legs / 203. / 0 / 1 / 2 / 3 / Restlesslegsyndrome
190. / 0 / 1 / 2 / 3 / Enlargedheartorcongestiveheartfailure / 204. / 0 / 1 / 2 / 3 / Cracksatcornerofmouth(Cheilosis)
191. / 0 / 1 / 2 / 3 / Pulsebelow65perminute(0=no,1=yes) / 205. / 0 / 1 / 2 / 3 / Fragileskin,easilychaffed,asin shaving
192. / 0 / 1 / 2 / 3 / Ringingintheears(Tinnitus) / 206. / 0 / 1 / 2 / 3 / Polypsorwarts
193. / 0 / 1 / 2 / 3 / Numbness,tinglingoritchingin handsand feet / 207. / 0 / 1 / 2 / 3 / MSGsensitivity
194. / 0 / 1 / 2 / 3 / Depressed / 208. / 0 / 1 / 2 / 3 / Wakeupwithoutrememberingdreams
195. / 0 / 1 / 2 / 3 / Fearofimpendingdoom / 209. / 0 / 1 / 2 / 3 / Smallbumpsonback of arms
196. / 0 / 1 / 2 / 3 / Worrier,apprehensive,anxious / 210. / 0 / 1 / 2 / 3 / Stronglightatnightirritateseyes
197. / 0 / 1 / 2 / 3 / Nervousoragitated / 211. / 0 / 1 / 2 / 3 / Nosebleedsand/ortendtobruiseeasily
198. / 0 / 1 / 2 / 3 / Feelingsofinsecurity / 212. / 0 / 1 / 2 / 3 / Bleedinggums especiallywhenbrushingteeth
199. / 0 / 1 / 2 / 3 / Heartraces
Section 9–Adrenal 78
213. / 0 / 1 / 2 / 3 / Tendto bea "nightperson" / 226. / 0 / 1 / 2 / 3 / Arthritictendencies
214. / 0 / 1 / 2 / 3 / Difficultyfallingasleep / 227. / 0 / 1 / 2 / 3 / Cravesaltyfoods
215. / 0 / 1 / 2 / 3 / Slowstarterin the morning / 228. / 0 / 1 / 2 / 3 / Saltfoodsbeforetasting
216. / 0 / 1 / 2 / 3 / Tendto bekeyedup,troublecalmingdown / 229. / 0 / 1 / 2 / 3 / Perspireeasily
217. / 0 / 1 / 2 / 3 / Bloodpressureabove120/80 / 230. / 0 / 1 / 2 / 3 / Chronicfatigue,orgetdrowsyoften
218. / 0 / 1 / 2 / 3 / Headacheafterexercising / 231. / 0 / 1 / 2 / 3 / Afternoonyawning
219. / 0 / 1 / 2 / 3 / Feelingwiredorjitteryafterdrinkingcoffee / 232. / 0 / 1 / 2 / 3 / Afternoonheadache
220. / 0 / 1 / 2 / 3 / Clenchorgrindteeth / 233. / 0 / 1 / 2 / 3 / Asthma,wheezingordifficultybreathing
221. / 0 / 1 / 2 / 3 / Calm ontheoutside,troubledontheinside / 234. / 0 / 1 / 2 / 3 / Painonthemedialorinnersideof the knee
222. / 0 / 1 / 2 / 3 / Chroniclowback pain,worsewithfatigue / 235. / 0 / 1 / 2 / 3 / Tendencytosprainanklesor "shinsplints"
223. / 0 / 1 / 2 / 3 / Becomedizzywhenstandingup suddenly / 236. / 0 / 1 / 2 / 3 / Tendencytoneedsunglasses
224. / 0 / 1 / 2 / 3 / Difficultymaintainingmanipulativecorrection / 237. / 0 / 1 / 2 / 3 / Allergiesand/orhives
225. / 0 / 1 / 2 / 3 / Painaftermanipulativecorrection / 238. / 0 / 1 / 2 / 3 / Weakness,dizziness
Section 10–Pituitary 29
239. / 0 / 1 / Heightover6'6"(0=no,1=yes) / 245. / 0 / 1 / Heightunder4'10" (0=no,1=yes)
240. / 0 / 1 / Earlysexualdevelopment(beforeage10)(0=no, / 246. / 0 / 1 / 2 / 3 / Decreasedlibido
1=yes) / 247. / 0 / 1 / 2 / 3 / Excessivethirst
241. / 0 / 1 / 2 / 3 / Increasedlibido / 248. / 0 / 1 / 2 / 3 / Weightgainaroundhipsorwaist
242. / 0 / 1 / 2 / 3 / Splittingtypeheadache / 249. / 0 / 1 / 2 / 3 / Menstrualdisorders
243. / 0 / 1 / 2 / 3 / Memoryfailing / 250. / 0 / 1 / Delayedsexualdevelopment(after age 13)
244. / 0 / 1 / Toleratesugar,feelfinewheneatingsugar
(0=no,1=yes) / 251. / 0 / 1 / 2 / 3 / (0=no,1=yes)
Tendencytoulcersor colitis

KEY: 0=No,symptomdoesnotoccur

1=Yes,minorormildsymptom,rarelyoccurs(monthly)

2=Moderatesymptom,occursoccasionally(weekly)

3=Severesymptom,occursfrequently(daily)

Section 11–Thyroid 48

252. / 0 / 1 / 2 / 3 / Sensitive/allergicto iodine / 260. / 0 / 1 / 2 / 3 / Mentallysluggish,reducedinitiative / 27
60
30
253. / 0 / 1 / 2 / 3 / Difficultygainingweight,evenwithlarge / 261. / 0 / 1 / 2 / 3 / Easilyfatigued,sleepyduringtheday
254. / 0 / 1 / 2 / 3 / appetite
Nervous,emotional,can'tworkunderpressure / 262. / 0 / 1 / 2 / 3 / Sensitivetocold, poorcirculation(coldhands
andfeet)
255. / 0 / 1 / 2 / 3 / Inwardtrembling / 263. / 0 / 1 / 2 / 3 / Constipation,chronic
256. / 0 / 1 / 2 / 3 / Flusheasily / 264. / 0 / 1 / 2 / 3 / Excessivehairlossand/orcoarsehair
257. / 0 / 1 / 2 / 3 / Fastpulseat rest / 265. / 0 / 1 / 2 / 3 / Morningheadaches,wearoffduringtheday
258. / 0 / 1 / 2 / 3 / Intolerancetohightemperatures / 266. / 0 / 1 / 2 / 3 / Lossoflateral1/3of eyebrow
259. / 0 / 1 / 2 / 3 / Difficultylosingweight / 267. / 0 / 1 / 2 / 3 / Seasonalsadness
Section 12–MenOnly
268. / 0 / 1 / 2 / 3 / Prostateproblems / 272. / 0 / 1 / 2 / 3 / Wakingto urinateat night
269. / 0 / 1 / 2 / 3 / Difficultywithurination,dribbling / 273. / 0 / 1 / 2 / 3 / Interruptionofstreamduringurination
270. / 0 / 1 / 2 / 3 / Difficultto start andstopurinestream / 274. / 0 / 1 / 2 / 3 / Painoninsideoflegsorheels
271. / 0 / 1 / 2 / 3 / Painorburningwithurination / 275. / 0 / 1 / 2 / 3 / Feelingof incompletebowelevacuation
276. / 0 / 1 / 2 / 3 / Decreasedsexualfunction
Section 13–WomenOnly
277. / 0 / 1 / 2 / 3 / Depressionduringperiods / 287. / 0 / 1 / 2 / 3 / Breastfibroids,benignmasses
278. / 0 / 1 / 2 / 3 / Moodswingsassociatedwithperiods(PMS) / 288. / 0 / 1 / 2 / 3 / Painfulintercourse(dysparenia)
279. / 0 / 1 / 2 / 3 / Cravechocolatearoundperiods / 289. / 0 / 1 / 2 / 3 / Vaginaldischarge
280. / 0 / 1 / 2 / 3 / Breasttendernessassociatedwithcycle / 290. / 0 / 1 / 2 / 3 / Vaginaldryness
281. / 0 / 1 / 2 / 3 / Excessivemenstrualflow / 291. / 0 / 1 / 2 / 3 / Vaginalitchiness
282. / 0 / 1 / 2 / 3 / Scantybloodflowduringperiods / 292. / 0 / 1 / 2 / 3 / Gain weightaroundhips,thighsandbuttocks
283. / 0 / 1 / 2 / 3 / Occasionalskippedperiods / 293. / 0 / 1 / 2 / 3 / Excessfacialorbodyhair
284. / 0 / 1 / 2 / 3 / Variationsinmenstrualcycles / 294. / 0 / 1 / 2 / 3 / Hotflashes
285. / 0 / 1 / 2 / 3 / Endometriosis / 295. / 0 / 1 / 2 / 3 / Nightsweats(inmenopausalfemales)
286. / 0 / 1 / 2 / 3 / Uterinefibroids / 296. / 0 / 1 / 2 / 3 / Thinningskin
Section 14– Cardiovascular
297. / 0 / 1 / 2 / 3 / Awareof heavyand/orirregularbreathing / 302. / 0 / 1 / 2 / 3 / Anklesswell,especiallyat endof day
298. / 0 / 1 / 2 / 3 / Discomfortathighaltitudes / 303. / 0 / 1 / 2 / 3 / Coughat night
299. / 0 / 1 / 2 / 3 / "Airhunger"orsighfrequently / 304. / 0 / 1 / 2 / 3 / Blushorfaceturnsredfornoreason
300. / 0 / 1 / 2 / 3 / Compelledtoopenwindowsina closedroom / 305. / 0 / 1 / 2 / 3 / Dull painortightnessinchestand/orradiate
301. / 0 / 1 / 2 / 3 / Shortnessof breathwithmoderateexertion / 306. / 0 / 1 / 2 / 3 / intorightarm,worsewithexertion
Musclecrampswithexertion
Section 15– KidneyandBladder / 13
307. / 0 / 1 2 / 3 Painin mid-backregion / 310. / 0 / 1 / 2 / 3 / Cloudy,bloodyordarkenedurine
308. / 0 / 1 2 / 3 Puffyaroundtheeyes,darkcirclesundereyes / 311. / 0 / 1 / 2 / 3 / Urinehasastrongodor
309. / 0 / 1 / Historyofkidneystones(0=no,1=yes)
Section 16– Immunesystem 30
312. / 0 1 / 2 3 / Runnyordrippynose / 317. / 0 / 1 / 2 / 3 / Neverget sick(0= sickonly1or2 timesinlast
313. / 0 1 / 2 3 / Catchcoldsat thebeginningof winter / 2 years,1 = notsickin last2 years,2 =not
314. / 0 1 / 2 3 / Mucusproducingcough / sickin last4years,3 =notsickinlast7 years)
315. / 0 1 / 2 3 / Frequentcoldsorflu (0=1orlessperyear,1=2 / 318. / 0 / 1 / 2 / 3 / Acne(adult)
to 3 times peryear,2=4 to 5 timesperyear,3=6 / 319. / 0 / 1 / 2 / 3 / Itchyskin(Dermatitis)
ormoretimesperyear) / 320. / 0 / 1 / 2 / 3 / Cysts,boils,rashes
316. / 0 1 / 2 3 / Otherinfections(sinus,ear, lung,skin,bladder,
kidney,etc.)(0=1orlessperyear,1=2to3 times peryear,2=4 to 5 timesperyear,3=6or moretimesperyear) / 321. / 0 / 1 / 2 / 3 / Historyof EpsteinBar,Mono,Herpes,
Shingles,ChronicFatigueSyndrome,Hepatitis orotherchronicviralcondition(0= no,1 =yes in thepast,2 =currentlymildcondition,3 =
severe)

KEY: 0=No,symptomdoesnotoccur

1=Yes,minorormildsymptom,rarelyoccurs(monthly)

2=Moderatesymptom,occursoccasionally(weekly)

3=Severesymptom,occursfrequently(daily)