Personal & Confidential Antioxidant Health Assessment
Health: Education, Income, Discipline Disease: Inflammation & Oxidative Stress

Prevention through Nutrition: “The amount of antioxidants that you maintain
in your body is directly proportional to how long you will live.” Dr. Richard Cutler NIH

Allergies / Medications:

What is your # 1 Health Concern?

Do you feel what you are doing is working?

How many servings of fresh fruits & vegetables do you eat daily?

Are you at your Ideal Weight?

How often do you exercise for thirty minutes or more a day?

How often you smoke?

Supplementation Assessment

Do you take supplements?

Yes

List all vitamins & supplements you take

Name
Brand
Dosage
Frequency

If yes, how did you select your supplements?

Estimated monthly supplement cost?

Are your supplements working?

Yes

Besides your number one health concern, please select any additional concerns you may have:

Select Additional Concern

Commitment to Care *

Nutritional Questionnaire

Simply put a check mark beside any symptom that applies to you

Part A (Stomach, Pancreas, Small Intestine)

Indigestion/gas after eating

Feel too full after eating, bloating

Sleepy or low energy after eating

Uncomfortable or adverse reactions after eating

Diet consists of mostly processed and cooked food

The need to eliminate soon after eating

large bowel movements daily

Part B (Colon)

Part C (Microbe, Yeast, Para)

Section 2 (Liver and Gallbladder)

Section 3 (Endocrine) Part A (Thyroid)

Part B (Adrenal)

Section 4 (Glucose) Part A (Glucose High)

Part B (Glucose Low)

Section 5 (Cardio)

Section 6 (Mood)

Section 7 (Immune)

Section 8 (Urinary)

Section 9 (Musculoskeletal)

Bones ache, feel tender or sore

Upper or lower back pain

Pain when sitting down or walking

Teeth are prone to decay

Joint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)

A routine exercise program, like daily walking, causes your knees to swell or hurt

Injure, strain or sprain easily

Muscles stiff, sore, tense and/or achy

Specific points on the body feel sore when pressed muscle cramps or spasms/twitches

Section 10 (CNS Brain)

Section 11-MALE ONLY (Prostate)

Section 12 - FEMALE ONLY (Hormones)

Indicate which conditions apply only if they occur within 14 days prior to and two days after
menstrual period: (Menopausal women skip to Part B)

Part A (PMS)

Part B (Hormones)

Section 13 (Specific Nutrients) Part A (Essential Fatty Acids)

Part B (Protein, Aminos)

Part C (CoQ10)

Part D (Vitamin C)

Part E (Vitamin D)

Part F (Iodine)

Please list any problems, symptoms or conditions that have not been covered in this questionnaire:

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