NUTRITIONAL ASSESSMENT QUESTIONNAIRE

PART 1 General Information

This will be filled in in clinic

Anus itchesCoated tongueLess than one bowel movement per dayStools loose or not well formedFeel worse in musty or mould atmosphereFungus or yeast infections( e.g. nail fungus, athletes foot, thrush)Stools hard or difficult to passHistory of parasite infectionCramps in lower abdominal regionRing worm, jock itch, athletes foot, nail fungusStool have corner’s or edges, are flat or ribbon shapedIrritable bowel syndromeBlood in stools, black or tarry stoolsMucus in stoolsSmelly bowel gasBad breathStrong body odourYeast symptoms increase with sugar, starch or alcoholDark circles under eyes

0 = no energy, 10 = lots of energy

0= no energy 10= high stress

0 = no sleep 10 = great sleep

PART 2

Please tick all of the symptoms that you are experiencing:

Discomfort at high altitudesAware of heavy and/or irregular breathingAir Hungry or sigh frequentlyCompelled to open windows in a closed roomAnkles swell, especially at the end of the dayDull pain or tightness in chest and/or radiate into right arm, worse with exertion.Cough at night, muscle cramp with exertionShortness of breath with moderate exertion

Prostate problemsDifficulty with urination, dribblingDifficulty to start or stop urine streamWaking to urinate at nightPain on inside of legs or heelFeeling of incomplete bowel evacuationPain or burning with urinationDecreased sexual function

PART 3 – DIET ANALYSIS