Health assessment form online to assess nutritional needs

Your Health and Nutrition
Report Questionnaire

Symptom Analysis

Your personal health and nutritional needs can be calculated by looking at your lifestyle and identifying signs and symptoms associated with various deficiencies. In the three separate sections that follow, answer the questions as best and as honestly as you can, then work out your score for each nutrient out of 10.

Your vitality depends upon a careful balance of at least fifty nutrients. Fortunately deficiency in protein, fat or carbohydrate is very rare. Unfortunately, deficiency in vitamins, minerals and essential fats is not. As few as 1 in 10 people receive enough nutrients from their diet for optimum health.

For each symptom that you experience often, tick the box, and score 1 point. Many symptoms occur more than once, because they can be the result of many nutrient deficiencies. If you experience any symptoms in Bold Type score 2 points.

The maximum score for each nutrient is 10 points. Put your score for each nutrient in the box that follows each section.

If none of the statements fit your profile, then please place a "0" in the score box rather than leave it blank.

Health Report Questionnaire - Part 1 -Vitamin profile

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Height (feet and Inches) e.g. 5' 5"*
Height (feet and Inches) e.g. 5' 5"*

Weight (stones and Pounds) e.g. 9st 4lb

How would you like to receive the report?*
How would you like to receive the report?*

Vitamin A *
Vitamin A *

	Mouth Ulcers
	Poor night vision
	Acne
	Frequent Colds and Infections
	Dry Flaky skin
	Dandruff
	Thrush/cystitis
	Diarrhoea

Vitamin A Score*
Vitamin A Score*

Vitamin D

	Arhritis or osteoporsis
	Backache
	Tooth decay
	Hair Loss
	Muscle twitching /spasms
	Joint pain or stiffness
	Weak Bones

Vitamin D Score*
Vitamin D Score*

Vitamin E

	Lack of sex drive
	Exhaustion after light exercise
	Easy Bruising
	Slow wound healing
	Varicose veins
	Poor skin elasticity
	Loss of muscle tone
	Infertility

Vitamin E Score*
Vitamin E Score*

Vitamin B2

	Bloodshot, painful or gritty eyes
	sensitivity to bright light
	Sore tongue
	Cataracts
	Dull or oily hair
	Eczema or dermatitis
	Split nails
	Cracked lips

Vitamin B2 Score*
Vitamin B2 Score*

Vitamin C

	Frequent colds
	Lack of energy
	Frequent infections
	Bleeding or tender gums
	Easy bruising
	Nose bleeds
	Slow wound healing
	Red pimples on skin

Vitamin C Score*
Vitamin C Score*

Vitamin B3 (niacin)

	Lack of energy
	Diarrhoea
	Insomnia
	Heachaches or migraines
	Poor memory
	Anxiety or tension
	Depression
	Irritability
	Bleeding or tender gums
	Acne

Vitamin B3 Score*
Vitamin B3 Score*

Vitamin B1

	Tender Muscles
	Eye Pains
	Irritability
	Poor concentration
	"Prickly" Legs
	Poor memory
	Stomach pains
	Tingling hands
	Rapid hearbeat
	Constipation

Vitamin B1 Score*
Vitamin B1 Score*

Vitamin B5

	Muscle Tremors, cramps or spasms
	Apathy
	Poor concentration
	Burning feet or tender heels
	Nausea or vomiting
	Lack of energy
	Exhaustion after light exercise
	Anxiety or tension
	Teeth grinding

Vitamin B5 Score*
Vitamin B5 Score*

Vitamin B6

	Infrequent dream call
	Water retention
	Tingling hands
	Depression or nervousness
	Irritability
	Muscle tremors, cramps and spasms
	Lack of energy

Vitamin B6 Score*
Vitamin B6 Score*

Folic Acid

	Eczema
	Cracked lips
	Prematurely greying hair
	Anxiety or tension
	Poor memory
	Lack of energy
	Depression
	Poor appetite
	Stomach pains

Folic Acid Score*
Folic Acid Score*

Vitamin B12

	Poor hair condition
	Eczema or dermatitis
	Mouth sensitive to hot/cold
	Irritability
	Anxiety or tension
	Lack of energy
	Constipation
	Tender or sore muscles
	Pale skin

Vitamin B12 Score*
Vitamin B12 Score*

Biotin - 2 points for each tick

	Dermatitis or dry skin
	Poor hair condition
	Prematurely greying hair
	Tender or sore muscles
	Poor appetite or nausea

Biotin Score*
Biotin Score*

Your Health and Nutrition Report Questionnaire

Your Health and Nutrition
Report Questionnaire