Metabolic and Nutritional Assessments-MANA



NUTRABALANCE HEALTH APPRAISAL QUESTIONNAIRE

INSTRUCTIONS:

Circle the number which best describes the intensity of your symptoms at this time or from your past history where indicated.

Total the scores for each section.

If you do not know the answer to a question, leave it blank.

0 = Symptom is not present 1 = Mild 2 = Moderate 3 = Severe

N = No Y = Yes

SCORING:

Add up the score for each section and write the totals in the spaces below. Be sure to enter your name, age, etc.

Answer 0-3 use corresponding number for points. Answers N = 0 points and Y = 3 points (*unless otherwise indicated.)

Name Age Sex Date / / __________

|PART |SECTION |TOTALS | |PART |SECTION |TOTALS |

| | | |

|PART I |SECTION A | | |PART VIII |SECTION A | |

|PART I |SECTION B | | |PART VIII |SECTION B | |

|PART I |SECTION C | | |PART VIII |SECTION C | |

|PART I |SECTION D | | | |

| | |PART IX |SECTION A | |

|PART II |SECTION A | | |PART IX |SECTION B | |

|PART II |SECTION B | | |PART IX |SECTION C | |

| | |PART IX |SECTION D | |

|PART III |COMPLETE | | |PART IX |SECTION E | |

| | | |

|PART IV |SECTION A | | |PART X |SECTION A | |

|PART IV |SECTION B | | |PART X |SECTION B | |

|PART IV |SECTION C | | | |

|PART V (MALES ONLY) | |PART XI |COMPLETE | |

| | | |

| | |PART XII |COMPLETE | |

|PART V |SECTION A | | | |

|PART V |SECTION B | | |PART XIII |COMPLETE | |

|PART V |SECTION C | | | |

|PART VI (FEMALES ONLY) | |PART XIV |COMPLETE | |

| | | |

| | |PART XV |COMPLETE | |

|PART VI |SECTION A | | | |

|PART VI |SECTION B | | |PART XVI |COMPLETE | |

|PART VI |SECTION C | | | |

|PART VI |SECTION D | | |PART XVII |COMPLETE | |

|PART VI |SECTION E | | | |

| | |PART XVIII |COMPLETE | |

|PART VII |SECTION A | | | |

|PART VII |SECTION B | | |PART XIX |COMPLETE | |

|PART VII |SECTION C | | | |

|PART I SECTION A |

|Temperature sensitivity………………………………. |

|Hypersensitive to odors/chemicals……………… |

|Excessive/deficient appetite………………………… |

|Chronic headaches………………………………………. |

|Recurrent dizziness/light headedness…………. |

|Memory problems……………………………………….. |

|Chronic hot or cold flashes………………………….. |

|Type A behavior/outburst……………………………. |

|Excessive Thirst……………………………………………. |

|Excessive sleep or insomnia…………………………. |

|History of heart disease……………………………….. |

| Decreased scalp hair…………………………………. |

|Increased body hair…………………………………… |

|Chronic headaches……………………………………. |

|Crave protein…………………………………………….. |

|Complete energy drop………………………………. |

|Menstrual irregularities…………………………….. |

|Dry or oily skin/hair…………………………………… |

|Hyper pigmentation of skin………………………. |

|Visual disturbances……………………………………. |

|Hyperactivity/chronic fatigue……………………. |

|Water retention………………………………………… |

| Extremely sensitive to environment………… |

|Migraine headaches…………………………………. |

|Epileptic seizures………………………………………. |

|Emotional ups and downs…………………………. |

|Multiple allergies……………………………………... |

|Impotency…………………………………………………. |

|Reduced sexual drive……………………………….. |

|Excessive sexual drive………………………………. |

|Recurrent anxiety…………………………………….. |

|Recurrent depression………………………………. |

|Visual problems………………………………………… |

| Loss of balance………………………………………… |

|Ringing/bussing in ears……………………………. |

|Trembling hands………………………………………. |

|Loss of feeling in hands and/or feet………… |

|Limbs feel heavy to hold up…………………….. |

|Loss of grip strength………………………………… |

|Tingling pain sensation……………………………. |

|Uncoordinated………………………………………… |

|Nervousness……………………………………………. |

|Nightmares………………………………………………. |

|Intense dreams………………………………………… |

|Leg cramps/restless legs at night…………….. |

|Frequent urination………………………………………. |

|Frequent bladder/kidney infections……………. |

|Rarely need to urinate………………………………… |

|Painful/burning when urinating………………….. |

|Difficulty passing urine……………………………….. |

|Dripping after urination………………………………. |

|Can’t hold urine…………………………………………… |

|Strong smelling urine………………………………….. |

|Water retention/bloating……………………………. |

|Flushed skin………………………………………………… |

|Blue nose, fingers, toes……………………………….. |

|Chronic headaches………………………………………. |

|Heart/circulatory problems…………………………. |

|Little urinary output………………………………….. |

|Unexplained weight gain…………………………… |

|Water retention/leg swelling…………………….. |

|Edema (swelling) around eyes & face……….. |

|Headaches or fatigue………………………………… |

|Visual difficulties………………………………………. |

|Blood in the urine…………………………………….. |

|Smoky or “coke colored” urine………………… |

|Abdominal pain or swelling………………………. |

|Lower flank (back) pain or mass……………….. |

|Repeated night time urination…………………. |

|Nausea or loss of appetite……………………….. |

|Urgency or frequency of urination…………… |

|Painful urination………………………………………. |

|Anemia…………………………………………………….. |

|Swollen eyes (bulging)……………………………… |

|Thick skin and fingernails…………………………. |

|Dry skin……………………………………………………. |

|Sensitive to the cold………………………………… |

|Cold hands and feet…………………………………. |

|Excessive menstrual bleeding………………….. |

|Chronic fatigue………………………………………… |

|Heart palpitations/hyperactivity……………… |

|Depressed/apathetic……………………………….. |

|Low sex drive……………………………………………. |

|Puffy/wrinkly skin…………………………………….. |

|Sugar causes irritability and mood swings… |

|Sensitive to exhaust fumes, smoke, smog, Petrochemicals…………………………………………… |

|Periodic constipation/diarrhea……………………. |

|Cannot tolerate much exercise………………….. |

|Depression or rapid mood swings………………. |

|Dark circles under the eyes…………………………. |

|Dizziness……………………………………………………… |

|Lack of mental alertness……………………………… |

|Catch colds easily when weather changes….. |

|Difficulty breathing……………………………………… |

|Water retention………………………………………….. |

|Eyes sensitive to bright light……………………….. |

|Feel weak and shaky…………………………………… |

|Muscle weakness………………………………………… |

|Pain in the morning in back of head/neck…. |

|Shortness of breath on exertion………………. |

|Chest pain while walking…………………………… |

|Calf muscles cramp while walking…………….. |

|Heart pounds easily/palpitations………………. |

|Heart skips beats or has extra beats…………. |

|Swelling of feet and ankles……………………….. |

|Rapid beating heart………………………………….. |

|Heartburn after eating……………………………… |

|Pain in left arm…………………………………………. |

|Cold hands and feet…………………………………. |

|Varicose veins………………………………………….. |

|Calf muscles cramp while walking……………. |

|Headaches (throbbing)…………………………….. |

|Numbness/blue color of extremities……….. |

|Poor concentration………………………………….. |

|Ringing in ears………………………………………….. |

|Frequent nose bleeds……………………………….. |

|Difficulty urinating…………………………………… |

|A sense of bladder fullness……………………… |

|Increased straining with smaller and smaller amounts of urine passed…………………………. |

|Rose colored (bloody) urine……………………. |

|Pain or burning while urinating……………….. |

|Difficulty attaining/maintaining an erection |

|Anxiety or fear of sexual intimacy with women…………………………………………………….. |

|Premature ejaculation……………………………… |

|Pain/coldness in genital area…………………… |

|Discharge from penis……………………………….. |

|Past or present rash on penis………………….. |

|Swollen genitals……………………………………….. |

|Swelling in groin………………………………………. |

|Monthly weight gain…………………………………… |

|Depression…………………………………………………. |

|Bloating and swelling…………………………………. |

|Moodiness /irritability……………………………….. |

|Nausea and/or vomiting…………………………….. |

|Anxiety/irritability……………………………………… |

|Leg cramps and tenderness………………………. |

|Craving for sugar/salt…………………………………. |

|Headaches…………………………………………………. |

|Vaginal itching/dryness……………………………. |

|Vaginal discharge/infection……………………… |

|Low or no desire for sex…………………………… |

|Dislike for intercourse………………………………. |

|Missed periods…………………………………………. |

|Over 15 years of age and have not begun menstruation*...……………………………………….. |

|Low abdominal pain…………………………………. |

|Dull ache radiating to low back or legs…….. |

|Increased urinary frequency……………………. |

|Pelvic soreness………………………………………… |

|Diarrhea…………………………………………………… |

|Headaches……………………………………………….. |

|Abdominal bloating………………………………….. |

|Menstrual pain/endometriosis………………… |

|Nausea and/or vomiting………………………….. |

|Have to lie down on first 1 or 2 days of period……………………………………………………… |

|Vaginal bumps and sores………………………… |

|Pubic area sore……………………………………….. |

|Pain in ovaries…………………………………………. |

|Breasts sore to touch………………………………. |

|Breasts painful/fibrocystic breasts………….. |

|Water retention/swollen feeling…………….. |

|Mother used D.E.S. (hormones) while pregnant………………………………………………….. |

|Recent Pap smear positive*…………………….. |

|Hot flashes………………………………………………. |

|Night sweats……………………………………………. |

|Depression/Mood swings………………………… |

|Insomnia………………………………………………….. |

|Heavy bleeding two weeks/month………….. |

|Sweating throughout day………………………… |

|Dryness of skin, hair and vagina………………. |

|Pain in fingers……………………………………………… |

|Tightness in shoulder muscles……………………. |

|Cavities………………………………………………………. |

|Arthritis……………………………………………………… |

|Drink carbonated beverages/soda…………….. |

|Gum disease………………………………………………. |

|Bone loss*…………………………………………………. |

|Calcium deposits*……………………………………… |

|Use antacids………………………………………………. |

|Muscle spasms/tetany……………………………… |

|Tightness in shoulder muscles…………………. |

|Muscle cramps…………………………………………. |

|Pain in arms and hands…………………………….. |

|Leg cramps at night………………………………….. |

|Stiff all over……………………………………………… |

|Over flexible joints (double jointed)………… |

|Back pain/bone pain……………………………….. |

|Swollen knees/elbows…………………………….. |

|Athletic injury………………………………………….. |

|Bursitis……………………………………………………… |

|Tendonitis………………………………………………… |

|Joint pain…………………………………………………. |

|Dizziness when standing suddenly………….. |

|Loss of vision when standing suddenly……. |

|Crave sweets/alcohol………………………………. |

|Headaches relieved by eating sweets or alcohol…………………………………………………….. |

|Feel shaky………………………………………………… |

|Irritable if a meal is missed………………………. |

|Wake up in the middle of the night craving sweets……………………………………………………… |

|Feel tired or weak if a meal is missed………. |

|Night sweats…………………………………………….. |

|Increased thirst/appetite…………………………. |

|Lowered resistance to infection………………. |

|Fatigue…………………………………………………….. |

|Boils and leg sores…………………………………… |

|Lesions, cuts take a long time to heal……… |

|Overweight……………………………………………… |

|Muscle weakness…………………………………….. |

|Frequent indigestion……………………………….. |

|Fullness in the abdomen…………………………. |

|Chronic digestive disturbances……………….. |

|Foul smelling stools…………………………………. |

|Chronic diarrhea……………………………………… |

|Chronic alcohol abuse*…………………………… |

|Burping………………………………………………………. |

|Fullness for extended time after meals……… |

|Bloating……………………………………………………… |

|Poor appetite…………………………………………….. |

|Stomach upsets easily……………………………….. |

|History of constipation*……………………………. |

|Abdominal cramps…………………………………… |

|Indigestion 1-3 hours after eating……………. |

|Fatigue after eating………………………………….. |

|Lower bowel gas………………………………………. |

|Alternation constipation and diarrhea…….. |

|Diarrhea (chronic)……………………………………. |

|Roughage and fiber causes constipation….. |

|Mucus in stools…………………………………………. |

|Stool poorly formed…………………………………. |

|Stomach pains/heartburn………………………… |

|Stomach pains just before and/or after meals……………………………………………………….. |

|Dependency on antacids………………………….. |

|Chronic abdominal pains………………………….. |

|Butterfly sensation in stomach…………………. |

|Difficulty belching…………………………………….. |

|Stomach pains when emotionally upset….. |

|Chronic bad breath…………………………………… |

|Sudden, acute indigestion………………………… |

|Seasonal diarrhea……………………………………. |

|Frequent recurrent infections (colds)………. |

|Bladder and kidney infections………………….. |

|Vaginal yeast infections……………………………. |

|Abdominal cramps……………………………………. |

|Toe and fingernail fungus (white growth)… |

|Alternation diarrhea/constipation……………. |

|Constipation/hemorrhoids……………………….. |

|History of frequent antibiotic use…………….. |

|Excessive stomach acid…………………………….. |

|Chronic diarrhea/constipation………………….. |

|Heartburn…………………………………………………. |

|Lack of appetite………………………………………… |

|Easy bruising…………………………………………….. |

|Recurrent depression………………………………. |

|Chronic fatigue…………………………………………. |

|Intolerance to fried foods………………………….. |

|Headache after eating……………………………….. |

|Light colored stool…………………………………….. |

|Foul smelling stool…………………………………….. |

|Easily bruisable………………………………………….. |

|Constipation………………………………………………. |

|Hard stool………………………………………………….. |

|Sour taste in mouth/bad breath……………….. |

|Grey colored skin………………………………………. |

|Yellow in whites of eyes……………………………. |

|Acne/skin eruptions………………………………….. |

|Body odor………………………………………………….. |

|Fatigue and sleepiness……………………………… |

|Pain in right side under rib cage……………….. |

|Chronic fatigue…………………………………………. |

|Toxic feeling……………………………………………… |

|Left upper abdominal pain……………………….. |

|Removal of spleen*………………………………….. |

|History of mononucleosis…………………………. |

|History of Hodgkins disease*……………………. |

|Recurrent/chronic anemia*……………………… |

|Inflamed or bleeding gums………………………. |

|Running nose……………………………………………. |

|Get boils/styes/cysts…………………………………. |

|Throat infections………………………………………. |

|Cold sores, fever blister……………………………. |

|Poor wound healing…………………………………. |

|Hives/rashes…………………………………………….. |

|Swollen lymph glands……………………………….. |

|Ear infections……………………………………………. |

|Acne………………………………………………………… |

|Slow to recover from cold and flu……………. |

|Catch colds or flu easily……………………………. |

|Muscle aches……………………………………………. |

|Swollen joints/joint pain…………………………… |

|Food sensitivity or allergy…………………………. |

|Certain foods make you sick, depressed, jittery………………………………………………………… |

|Chronic pain……………………………………………… |

|Mucus in throat………………………………………… |

|Post nasal drip………………………………………….. |

|Discharge from eyes or redness………………. |

|Eyes itch/puffiness……………………………………. |

|Nervousness/shakes……………………………………. |

|Sweaty palms………………………………………………. |

|Rapid heart beat/irregular…………………………… |

|Palpitations…………………………………………………. |

|Overweight (for you)…………………………………… |

|Can’t breathe deeply…………………………………… |

|Visual disturbances……………………………………… |

|Low back pain……………………………………………… |

|Neck tension/pain……………………………………….. |

|Muscle aches/cramps………………………………….. |

|Digestive difficulties…………………………………….. |

|Heartburn……………………………………………………. |

|Stress diarrhea…………………………………………….. |

| Not enough exercise………………………………….. |

|Too tired to exercise…………………………………… |

|Not enough time to exercise………………………. |

|Can’t fit it in my schedule……………………………. |

|Less than 3-4 times weekly………………………….. |

|Less than 2-3 times weekly………………………….. |

|Less than 1-2 times weekly………………………….. |

|Weight lifting only……………………………………….. |

|Aerobics not included…………………………………. |

|Get enough at work*…………………………………… |

| Lack of motivation to do much when I get home…………………………………………………………… |

|Feel guilty about not exercising………………….. |

|Little drive to accomplish much………………….. |

|Life is a boring routine…………………………………. |

|Too much work/too little pay……………………… |

|Gulp down my food quickly………………………… |

|Don’t relax after eating……………………………….. |

|Dining atmosphere is tense………………………… |

|Don’t exercise enough………………………………… |

|Nothing to really work for…………………………… |

|Lack of support from friends……………………….. |

|Difficulty with spouse…………………………………. |

|Misunderstood by others…………………………… |

|Needs are not being met…………………………….. |

|Lose friendships easily………………………………… |

|Little contact with family members…………….. |

|Don’t have love in my life…………………………… |

|Problems relating to my children……………….. |

|I probably give too much to others…………….. |

|I feel the need to please people to be liked… |

|I hold back to protect myself………………………. |

|I tend to rescue people at my expense………. |

|I feel withdrawn from my primary relationship partner…………………………………….. |

|Outbursts of anger………………………………………. |

|Short/quick tempered…………………………………. |

|Feel like I’m not good enough…………………….. |

|Feel sad a lot……………………………………………….. |

|Can’t get motivated…………………………………….. |

|Low energy………………………………………………….. |

|Feel nervous a lot………………………………………… |

|Feel worthless/hopeless……………………………… |

|Overwhelmed by problems…………………………. |

|Sleepy during the day………………………………….. |

|Feel anxious or “on edge”…………………………… |

|Irritable……………………………………………………….. |

|Worrying…………………………………………………….. |

|Feel uptight…………………………………………………. |

|Don’t get enough sleep……………………………….. |

|Don’t get enough relaxation……………………….. |

|Can’t get enough sleep……………………………….. |

|Haven’t learned how to relax……………………… |

|Don’t stop to smell the flowers…………………… |

|Can’t enjoy the simple things in life……………. |

|Feel torn in different directions………………….. |

|Now way to “tune out” the stress………………. |

|Chronic insomnia………………………………………… |

|Feel “moody” most of the time…………………… |

|Get the “winter blues”……………………………….. |

|Moody after eating sugar……………………………. |

|When I’m sad, it can easily turn to anger……. |

|Blunted response to humor/jokes………………. |

|Laugh inappropriately…………………………………. |

|Emotions wander a lot………………………………… |

|Don’t get close to other people………………….. |

|Afraid to hug or be hugged…………………………. |

|Often get “giggly”………………………………………… |

|Feel uncomfortable with comedy……………….. |

|Learn tasks slowly………………………………………. |

|Don’t fit in well with my friends…………………. |

|Make the same mistakes…………………………….. |

|Fall short of my expectations……………………… |

|Often seem out of place…………………………….. |

|Can’t get along with the opposite sex………… |

|Unhappy with my boss/employer………………. |

|Need a career change…………………………………. |

|Often become annoyed……………………………… |

|Difficult to do unpleasant chores………………. |

|Ignore things that annoy me……………………… |

|Can’t stand to take chances………………………. |

|Trouble accepting things the way they are… |

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