Free Nutritional Evaluation

This nutritional questionnaire will provide you with an understanding of your current nutritional health status and what supplements from Whole-istic Solutions are suggested for you.

Instructions
The items in this questionnaire refer to nutritional health. Please read each item carefully and decide to what extent it is characteristic of you. Give each item a rating of how much it applies to you by selecting the appropriate radio button.

Choose the best answer to each section, responding to every question even if you are not completely sure.

QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you have excessive hunger?
Do you have food allergies?
Do you experience indigestion after meals?
Do you experience reflux?
Do you have abdominal bloating or feel gaseous after meals?
Do you feel fullness for extended times after eating (2-3 hours after meals)?
Does roughage or fiber give you constipation?
Do you have diarrhea after eating?
Do you experience low energy or get sleepy after eating?
Do you have difficulty breathing after eating?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do your muscles feel weak after performing normal daily activities?
Do you consume fewer than 3 servings of fruit and vegetables daily?
Do you consume fewer than 3 servings of whole grain daily?
Do you eat white flour products (breads, pasta, crackers, muffins, cookies, etc.)?
Do you drink alcoholic beverages?
Do you drink soda or other carbonated beverages?
Do you use tobacco products?
Do you eat fried foods?
Do you feel nervous and unable to concentrate?
Do you have low energy and/or low stamina?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience persistant illnesses?
Do you suffer from painful joints?
Do you have food allergies?
Do you drink alcoholic beverages?
Do you drink soda or any carbonated beverages
Do you use tobacco products?
Do you eat chicken or red meat?
Do you get heartburn?
Do you have abdominal bloating or feel gasseous after meals?
Do you get constipated and/or have diarrhea?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience fevers or infections?
Do you have disc problems?
Do you suffer from painful joints?
Do you experience difficulty in strengthening muscles?
Do your muscles feel very tight or congested?
Do you have muscle pain or cramps?
Are your injuries slow to heal?
Have you experienced any significant injuries in the last couple of months?
Are you or have you been on a high protein diet?
Do you have poor circulation or get cold hands and/or feet?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience persistent illness?
Are you unable to get good results from antibiotics?
Do you have Candida Albicans?
Do you experience Athlete's Foot?
Do you experience fevers or infections?
Do you get fungal infections?
Do you get yeast infections?
Do you suffer from bad breath?
Do you have food allergies?
Do you experience anal itching?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you have a history of joint injury?
Do you have arthritis?
Do you have bursitis or tendonitis?
Do you have extreme flexibility in your joints (double-jointed)?
Do you suffer from back pain?
Do you have pain in your fingers or wrists?
Do you have pain in your knees and/or hips?
Do you suffer from swollen joints?
Do your bones ache or feel painfully sore?
Do you wake up stiff and tight?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience fevers or infections?
Do you get fever blisters or mouth ulcers?
Do you suffer from digestive ulcers?
Do you have seasonal allergies?
Do you have a high stress lifestyle?
Do you suffer from depression?
Do you feel nervous and unable to concentrate?
Do you have a hard time remembering things?
Do you have trouble falling asleep or staying asleep at night?
Do you have low energy and/or low stamina?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you suffer from or have a family history of osteoporosis?
Do you have muscle pain or cramps?
Do you drink soda or any carbonated beverages?
Do you use tobacco products?
Do you get heartburn?
Do you have high blood pressure?
Are you 40 years of age or older?
Do you have restless leg syndrome?
Do you suffer from migraine type headaches?
Do you have trouble falling asleep or staying asleep at night?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience fevers or infections?
Do you suffer from painful joints?
Do you have low iron?
Is your HDL (good cholesterol) low?
Are strokes or heart disease in your history (or family history)?
Do you have cataracts or poor eyesights?
Do you have cancer in your history or family history?
Do you have long bouts of stress?
Do you have trouble falling asleep or staying asleep at night?
Do you have low energy and/or low stamina?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you have Candida Albicans?
Do you get fungal infections?
Do you get fungus under your fingernails or toenails?
Do you get yeast infections?
Do you have sugar cravings?
Do you have food allergies?
Do you eat white flour products (breads, pasta, crackers, muffins, cookies, etc.)?
Do you drink alcoholic beverages?
Do you drink soda or any carbonated beverages?
Do you have seasonal allergies?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you have arthritis?
Do you have chronic pain?
Do you have high cholesterol (over 200)?
Do you have cataracts or poor eyesight?
Do you look older than you are?
Do you suffer from a degenerative disease (MS, Rheumatoid Arthritis, Cancer)?
Do you have a high stress lifestyle?
Do you have a hard time remembering things?
Do you perform high-inelevensity workouts?
Do you travel by air?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you suffer from painful joints?
Do you suffer from stiffness of joints?
Are your injuries slow to heal?
Do you drink alcoholic beverages?
Do you have high cholesterol (over 200)?
Do you have high blood pressure?
Do you have seasonal allergies?
Is stroke or heart disease in your history (or family history)?
Do you suffer from depression?
Do you have a hard time remembering things?
QUESTIONS	NEVER/ NO	RARELY	SOME- TIMES	OFTEN	ALWAYS/ YES
Do you experience persistent illness?
Do you get fever blisters or mouth ulcers?
Do you suffer from sinus problems?
Do you suffer from painful joints?
Do you have food allergies?
Do you have diarrhea after eating?
Do you have seasonal allergies?
Do you suffer from a degenerative disease (MS, Rheumatoid Arthritis, Cancer)?
Do you have a history of stomach or colon problems?
Do you get sick around the same time each year?

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