Nutritional Assessment Questionnaire Column One Full Name Gender Column Two Date Birth Date Full Width Column Please list your five major health concerns in order of importance: 1: 2: 3: 4: 5: Part One Read the following questions and circle the number that applies: 0 = Do not consume or use 1 = Consume or use 2 to 3 times monthly 2 = Consume or use weekly 3 = Consume or use daily Diet Column One Alcohol 0 1 2 3 Radiation exposure (0=no, 1=yes) 0 1 Caffeinated beverages 0 1 2 3 Candy, desserts, refined sugar 0 1 2 3 Vitamins and minerals 0 1 2 3 Fried foods 0 1 2 3 Luncheon meats 0 1 2 3 Chewing tobacco 0 1 2 3 Water, well 0 1 2 3 Milk products 0 1 2 3 Column Two Cigars/Pipes 0 1 2 3 Artificial sweeteners 0 1 2 3 Refined flour/baked goods 0 1 2 3 Fast foods 0 1 2 3 Carbonated beverages 0 1 2 3 Water, distilled 0 1 2 3 Water, tap 0 1 2 3 Margarine 0 1 2 3 Cigarettes 0 1 2 3 Diet often for weight control 0 1 2 3 If you are human, leave this field blank. Submit
