Ccnmihc.ca

Renée Isaacs Langdon, BSc (Hons), MSc, ND
CCNM Integrated Healthcare Centre, 1255 Sheppard Avenue East Toronto, ON M2K 1E2, Phone: (416) 498-8265 Nutritional Assessment Questionnaire
pt.: ____________________________________________ DOB: _______________ M F Date: _______________

Please list your four major health concerns in order of importance:
1. ______________________________________
3. ______________________________________
2. ______________________________________
4. ______________________________________
PART I Read the following questions and circle the number that applies:

KEY: 0 = Do not consume or use
2 = Consume or use weekly
1 = Consume or use 2 to 3 times monthly
3 = Consume or use daily
1. 0 1 2 3 Alcohol
7. 0 1 2 3 Cigars/pipes
14. 0 1 Radiation exposure (0=no, 1 =yes)
2. 0 1 2 3 Artificial sweeteners 8. 0 1 2 3 Caffeinated beverages 15. 0 1 2 3 Refined flour/baked goods
3. 0 1 2 3 Candy, desserts, refined 9. 0 1 2 3 Fast foods
16. 0 1 2 3 Vitamins and minerals
10. 0 1 2 3 Fried foods
17. 0 1 2 3 Water, distilled
4. 0 1 2 3 Carbonated beverages 11. 0 1 2 3 Luncheon meats
18. 0 1 2 3 Water, tap
5. 0 1 2 3 Chewing tobacco 12. 0 1 2 3 Margarine
19. 0 1 2 3 Water, well
6. 0 1 2 3 Cigarettes 13. 0 1 2 3 Milk products
20. 0 1 2 3 Diet often for weight control
LIFESTYLE

21. 0 1 2 3 Exercise per week (0 = 2 or more times a week, 1=1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a month)
22. 0 1 2 3 Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months)
23. 0 1 2 3 Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months)
24. 0 1 2 3 Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always)
MEDICATIONS Indicate any medications you're currently taking or have taken in the last month (0=no, 1=yes): 54
25. 0 1 Antacids
39. 0 1 Diuretics
26. 0 1 Antianxiety medications
40. 0 1 Estrogen or progesterone (pharmaceutical, prescription)
27. 0 1 Antibiotics
41. 0 1 Estrogen or progesterone (natural)
28. 0 1 Anticonvulsants
42. 0 1 Heart medications
29. 0 1 Antidepressants
43. 0 1 High blood pressure medications
30. 0 1 Antifungals
44. 0 1 Laxatives
31. 0 1 Aspirin/lbuprofen
45. 0 1 Recreational drugs
32. 0 1 Asthma inhalers
46. 0 1 Relaxants/Sleeping pills
33. 0 1 Beta blockers
47. 0 1 Testosterone (natural or prescription)
34. 0 1 Birth control pills/implant contraceptives 48. 0 1 Thyroid medication
35. 0 1 Chemotherapy
49. 0 1 Acetaminophen (Tylenol)
36. 0 1 Cholesterol lowering medications
50. 0 1 Ulcer medications
37. 0 1 Cortisone/steroids
51. 0 1 Sildenafil citrate (Viagra)
38. 0 1 Diabetic medications/insulin
PART II (See key at bottom of page)

Section 1

52. 0 1 2 3 Belching or gas within one hour after eating 61. 0 1 2 3 Feel like skipping breakfast
53. 0 1 2 3 Heartburn or acid reflux
62. 0 1 2 3 Feel better if you don't eat
54. 0 1 2 3 Bloating within one hour after eating 63. 0 1 2 3 Sleepy after meals
55. 0 1 Vegan diet (no dairy, meat, fish or eggs) (0=no, 64. 0 1 2 3 Fingernails chip, peel or break easily
1=yes)
65. 0 1 2 3 Anemia unresponsive to iron
56. 0 1 2 3 Bad breath (halitosis)
66. 0 1 2 3 Stomach pains or cramps
57. 0 1 2 3 Loss of taste for meat
67. 0 1 2 3 Diarrhea, chronic
58. 0 1 2 3 Sweat has a strong odor
68. 0 1 2 3 Diarrhea shortly after meals
59. 0 1 2 3 Stomach upset by taking vitamins 69. 0 1 2 3 Black or tarry colored stools
60. 0 1 2 3 Sense of excess fullness after meals 70. 0 1 2 3 Undigested food in stool
KEY: 0=No, symptom does not occur 2=Moderate symptom, occurs occasionally (weekly) 1=Yes, minor or mild symptom, rarely occurs (monthly) 3=Severe symptom, occurs frequently (daily) Renée Isaacs Langdon, BSc (Hons), MSc, ND
CCNM Integrated Healthcare Centre, 1255 Sheppard Avenue East Toronto, ON M2K 1E2, Phone: (416) 498-8265 pt: ____________________________________________________________ Nutritional Assessment Questionnaire
Page 2 of 4
Section 2
71. 0 1 2 3 Pain between shoulder blades
85. 0 1 Easily hung over if you were to drink wine (0=no,
72. 0 1 2 3 Stomach upset by greasy foods
73. 0 1 2 3 Greasy or shiny stools
86. 0 1 2 3 Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14)
74. 0 1 2 3 Nausea
87. 0 1 Recovering alcoholic (0=no, 1 =yes)
75. 0 1 2 3 Sea, car, airplane or motion sickness
88. 0 1 History of drug or alcohol abuse (0=no, 1=yes)
76. 0 1 History of morning sickness (0 = no, 1 = yes)
89. 0 1 History of hepatitis (0=no, 1 =yes)
77. 0 1 2 3 Light or clay colored stools
90. 0 1 Long term use of prescription/recreational drugs
78. 0 1 2 3 Dry skin, itchy feet or skin peels on feet
79. 0 1 2 3 Headache over eyes
91. 0 1 2 3 Sensitive to chemicals (perfume, cleaning agents, etc)
80. 0 1 2 3 Gallbladder attacks (0=never, 1=years ago,
92. 0 1 2 3 Sensitive to tobacco smoke
2=within last year, 3=within past 3 months) 93. 0 1 2 3 Exposure to diesel fumes
81. 0 1 Gallbladder removed (0=no, 1 =yes)
94. 0 1 2 3 Pain under right side of rib cage
82. 0 1 2 3 Bitter taste in mouth, especially after meals
95. 0 1 2 3 Hemorrhoids or varicose veins
83. 0 1 Become sick if you were to drink wine (0=no,
96. 0 1 2 3 Nutrasweet (aspartame) consumption
97. 0 1 2 3 Sensitive to Nutrasweet (aspartame)
84. 0 1 Easily intoxicated if you were to drink wine
98. 0 1 2 3 Chronic fatigue or Fibromyalgia
Section 3
99. 0 1 2 3 Food allergies
108. 0 1 2 3 Crohn's disease (0 =no, 1 =yes in the past,
100. 0 1 2 3 Abdominal bloating 1 to 2 hours after eating
101. 0 1 Specific foods make you tired or bloated (0=no,
109. 0 1 2 3 Wheat or grain sensitivity
110. 0 1 2 3 Dairy sensitivity
102. 0 1 2 3 Pulse speeds after eating
111. 0 1 Are there foods you could not give up (0=no,
103. 0 1 2 3 Airborne allergies
104. 0 1 2 3 Experience hives
112. 0 1 2 3 Asthma, sinus infections, stuffy nose
105. 0 1 2 3 Sinus congestion, "stuffy head"
113. 0 1 2 3 Bizarre vivid dreams, nightmares
106. 0 1 2 3 Crave bread or noodles
114. 0 1 2 3 Use over-the-counter pain medications
107. 0 1 2 3 Alternating constipation and diarrhea
115. 0 1 2 3 Feel spacey or unreal
Section 4
116. 0 1 2 3 Anus itches
126. 0 1 2 3 Stools have comers or edges, are flat or ribbon
117. 0 1 2 3 Coated tongue
118. 0 1 2 3 Feel worse in moldy or musty place
127. 0 1 2 3 Stools are not well formed (loose)
119. 0 1 2 3 Taken antibiotic for a total accumulated time of
128. 0 1 2 3 Irritable bowel or mucus colitis
(0=never, 1= <1 month, 2= <3 months, 3= >3 129. 0 1 2 3 Blood in stool
130. 0 1 2 3 Mucus in stool
120. 0 1 2 3 Fungus or yeast infections
131. 0 1 2 3 Excessive foul smelling lower bowel gas
121. 0 1 2 3 Ring worm, "jock itch", "athletes foot", nail fungus
132. 0 1 2 3 Bad breath or strong body odors
122. 0 1 2 3 Yeast symptoms increase with sugar, starch or
133. 0 1 2 3 Painful to press along outer sides of thighs
123. 0 1 2 3 Stools hard or difficult to pass
134. 0 1 2 3 Cramping in lower abdominal region
124. 0 1 History of parasites (0=no, 1=yes)
135. 0 1 2 3 Dark circles under eyes
125. 0 1 2 3 Less than one bowel movement per day
Section 5
136. 0 1 History of carpal tunnel syndrome (0=no, 1=yes)
150. 0 1 History of bone spurs (0=no, 1=yes)
137. 0 1 History of lower right abdominal pains or
151. 0 1 2 3 Morning stiffness
Ileocecal valve problems (0=no, 1 =yes) 152. 0 1 2 3 Nausea with vomiting
138. 0 1 History of stress fracture (0=no, 1=yes)
153. 0 1 2 3 Crave chocolate
139. 0 1 2 3 Bone loss (reduced density on bone scan)
154. 0 1 2 3 Feet have a strong odor
140. 0 1 Are you shorter than you used to be? (0=no,
155. 0 1 2 3 History of anemia
156. 0 1 2 3 Whites of eyes (sclera) blue tinted
141. 0 1 2 3 Calf, foot or toe cramps at rest
157. 0 1 2 3 Hoarseness
142. 0 1 2 3 Cold sores, fever blisters or herpes lesions
158. 0 1 2 3 Difficulty swallowing
143. 0 1 2 3 Frequent fevers
159. 0 1 2 3 Lump in throat
144. 0 1 2 3 Frequent skin rashes and/or hives
160. 0 1 2 3 Dry mouth, eyes and/or nose
145. 0 1 Herniated disc (0=no, 1=yes)
161. 0 1 2 3 Gag easily
146. 0 1 2 3 Excessively flexible joints, "double jointed"
162. 0 1 2 3 White spots on fingernails
147. 0 1 2 3 Joints pop or click
163. 0 1 2 3 Cuts heal slowly and/or scar easily
148. 0 1 2 3 Pain or swelling in joints
164. 0 1 2 3 Decreased sense of taste or smell
149. 0 1 2 3 Bursitis or tendonitis
KEY: 0=No, symptom does not occur 2=Moderate symptom, occurs occasionally (weekly) 1=Yes, minor or mild symptom, rarely occurs (monthly) 3=Severe symptom, occurs frequently (daily) Renée Isaacs Langdon, BSc (Hons), MSc, ND
CCNM Integrated Healthcare Centre, 1255 Sheppard Avenue East Toronto, ON M2K 1E2, Phone: (416) 498-8265

pt: ____________________________________________________________ Nutritional Assessment Questionnaire
Page 3 of 4
Section 6
165. 0 1 Experience pain relief with aspirin (0=no, 1=yes)
169. 0 1 2 3 Headaches when out in the hot sun
166. 0 1 2 3 Crave fatty or greasy foods
170. 0 1 2 3 Sunburn easily or suffer sun poisoning
167. 0 1 2 3 Low-or reduced-fat diet (0=never, 1=years ago,
171. 0 1 2 3 Muscles easily fatigued
172. 0 1 2 3 Dry flaky skin or dandruff
168. 0 1 2 3 Tension headaches at base of skull
Section 7
173. 0 1 2 3 Awaken a few hours after falling asleep, hard to
180. 0 1 2 3 Headache if meals are skipped or delayed
181. 0 1 2 3 Irritable before meals
174. 0 1 2 3 Crave sweets
182. 0 1 2 3 Shaky if meals delayed
175. 0 1 2 3 Binge or uncontrolled eating
183. 0 1 2 3 Family members with diabetes (0=none,
176. 0 1 2 3 Excessive appetite
177. 0 1 2 3 Crave coffee or sugar in the afternoon
184. 0 1 2 3 Frequent thirst
178. 0 1 2 3 Sleepy in afternoon
185. 0 1 2 3 Frequent urination
179. 0 1 2 3 Fatigue that is relieved by eating
Section 8
186. 0 1 2 3 Muscles become easily fatigued
200. 0 1 2 3 Can hear heart beat on pillow at night
187. 0 1 2 3 Feel exhausted or sore after moderate exercise
201. 0 1 2 3 Whole body or limb jerk as falling asleep
188. 0 1 2 3 Vulnerable to insect bites
202. 0 1 2 3 Night sweats
189. 0 1 2 3 Loss of muscle tone, heaviness in arms/legs
203. 0 1 2 3 Restless leg syndrome
190. 0 1 2 3 Enlarged heart or congestive heart failure
204. 0 1 2 3 Cracks at comer of mouth (Cheilosis)
191. 0 1 2 3 Pulse below 65 per minute (0=no, 1=yes)
205. 0 1 2 3 Fragile skin, easily chaffed, as in shaving
192. 0 1 2 3 Ringing in the ears (Tinnitus)
206. 0 1 2 3 Polyps or warts
193. 0 1 2 3 Numbness, tingling or itching in hands and feet
207. 0 1 2 3 MSG sensitivity
194. 0 1 2 3 Depressed
208. 0 1 2 3 Wake up without remembering dreams
195. 0 1 2 3 Fear of impending doom
209. 0 1 2 3 Small bumps on back of arms
196. 0 1 2 3 Worrier, apprehensive, anxious
210. 0 1 2 3 Strong light at night irritates eyes
197. 0 1 2 3 Nervous or agitated
211. 0 1 2 3 Nose bleeds and/or tend to bruise easily
198. 0 1 2 3 Feelings of insecurity
212. 0 1 2 3 Bleeding gums especially when brushing teeth
199. 0 1 2 3 Heart races
Section 9
213. 0 1 2 3 Tend to be a "night person"
226. 0 1 2 3 Arthritic tendencies
214. 0 1 2 3 Difficulty falling asleep
227. 0 1 2 3 Crave salty foods
215. 0 1 2 3 Slow starter in the morning
228. 0 1 2 3 Salt foods before tasting
216. 0 1 2 3 Tend to be keyed up, trouble calming down
229. 0 1 2 3 Perspire easily
217. 0 1 2 3 Blood pressure above 120/80
230. 0 1 2 3 Chronic fatigue, or get drowsy often
218. 0 1 2 3 Headache after exercising
231. 0 1 2 3 Afternoon yawning
219. 0 1 2 3 Feeling wired or jittery after drinking coffee
232. 0 1 2 3 Afternoon headache
220. 0 1 2 3 Clench or grind teeth
233. 0 1 2 3 Asthma, wheezing or difficulty breathing
221. 0 1 2 3 Calm on the outside, troubled on the inside
234. 0 1 2 3 Pain on the medial or inner side of the knee
222. 0 1 2 3 Chronic low back pain, worse with fatigue
235. 0 1 2 3 Tendency to sprain ankles or "shin splints"
223. 0 1 2 3 Become dizzy when standing up suddenly
236. 0 1 2 3 Tendency to need sunglasses
224. 0 1 2 3 Difficulty maintaining manipulative correction
237. 0 1 2 3 Weakness, dizziness
Section 10
239. 0 1 Height over 6'6" (0=no, 1=yes)
245. 0 1 Height under 4' 10" (0=no, 1=yes)
240. 0 1 Early sexual development (before age 10) (0=no,
246. 0 1 2 3 Decreased libido
247. 0 1 2 3 Excessive thirst
241. 0 1 2 3 Increased libido
248. 0 1 2 3 Weight gain around hips or waist
242. 0 1 2 3 Splitting type headache
249. 0 1 2 3 Menstrual disorders
243. 0 1 2 3 Memory failing
250. 0 1 Delayed sexual development (after age 13)
244. 0 1 Tolerate sugar, feel fine when eating sugar
251. 0 1 2 3 Tendency to ulcers or colitis
KEY: 0=No, symptom does not occur 2=Moderate symptom, occurs occasionally (weekly) 1=Yes, minor or mild symptom, rarely occurs (monthly) 3=Severe symptom, occurs frequently (daily) Renée Isaacs Langdon, BSc (Hons), MSc, ND
CCNM Integrated Healthcare Centre, 1255 Sheppard Avenue East Toronto, ON M2K 1E2, Phone: (416) 498-8265
pt: ____________________________________________________________ Nutritional Assessment Questionnaire
Page 4 of 4
Section 11
252. 0 1 2 3 Sensitive/allergic to iodine
260. 0 1 2 3 Mentally sluggish, reduced initiative
253. 0 1 2 3 Difficulty gaining weight, even with large
261. 0 1 2 3 Easily fatigued, sleepy during the day
262. 0 1 2 3 Sensitive to cold, poor circulation (cold hands
254. 0 1 2 3 Nervous, emotional, can't work under pressure
255. 0 1 2 3 Inward trembling
263. 0 1 2 3 Constipation, chronic
256. 0 1 2 3 Flush easily
264. 0 1 2 3 Excessive hair loss and/or coarse hair
257. 0 1 2 3 Fast pulse at rest
265. 0 1 2 3 Morning headaches, wear off during the day
258. 0 1 2 3 Intolerance to high temperatures
266. 0 1 2 3 Loss of lateral 1/3 of eyebrow
259. 0 1 2 3 Difficulty losing weight
267. 0 1 2 3 Seasonal sadness
Section 12 - Men Only
268. 0 1 2 3 Prostate problems 272. 0 1 2 3 Waking to urinate at night
269. 0 1 2 3 Difficulty with urination, dribbling 273. 0 1 2 3 Interruption of stream during urination
270. 0 1 2 3 Difficult to start and stop urine stream 274. 0 1 2 3 Pain on inside of legs or heels
271. 0 1 2 3 Pain or burning with urination
275. 0 1 2 3 Feeling of incomplete bowel evacuation
276. 0 1 2 3 Decreased sexual function
Section 13 - Women Only
277. 0 1 2 3 Depression during periods
287. 0 1 2 3 Breast fibroids, benign masses
278. 0 1 2 3 Mood swings associated with periods (PMS)
288. 0 1 2 3 Painful intercourse (dysparenia)
279. 0 1 2 3 Crave chocolate around periods
289. 0 1 2 3 Vaginal discharge
280. 0 1 2 3 Breast tenderness associated with cycle
290. 0 1 2 3 Vaginal dryness
281. 0 1 2 3 Excessive menstrual flow
291. 0 1 2 3 Vaginal itchiness
282. 0 1 2 3 Scanty blood flow during periods
292. 0 1 2 3 Gain weight around hips, thighs and buttocks
283. 0 1 2 3 Occasional skipped periods
293. 0 1 2 3 Excess facial or body hair
284. 0 1 2 3 Variations in menstrual cycles
294. 0 1 2 3 Hot flashes
285. 0 1 2 3 Endometriosis
295. 0 1 2 3 Night sweats (in menopausal females)
286. 0 1 2 3 Uterine fibroids
296. 0 1 2 3 Thinning skin
Section 14
297. 0 1 2 3 Aware of heavy and/or irregular breathing
302. 0 1 2 3 Ankles swell, especially at end of day
298. 0 1 2 3 Discomfort at high altitudes
303. 0 1 2 3 Cough at night
299. 0 1 2 3 "Air hunger" or sigh frequently
304. 0 1 2 3 Blush or face turns red for no reason
300. 0 1 2 3 Compelled to open windows in a closed room
305. 0 1 2 3 Dull pain or tightness in chest and/or radiate
301. 0 1 2 3 Shortness of breath with moderate exertion
306. 0 1 2 3 Muscle cramps with exertion
Section 15
307. 0 1 2 3 Pain in mid-back region
310. 0 1 2 3 Cloudy, bloody or darkened urine
308. 0 1 2 3 Puffy around the eyes, dark circles under eyes
311. 0 1 2 3 Urine has a strong odor
309. 0 1 History of kidney stones (0=no, 1=yes)
Section 16
312. 0 1 2 3 Runny or drippy nose
317. 0 1 2 3 Never get sick (0 = sick only 1 or 2 times in last
313. 0 1 2 3 Catch colds at the beginning of winter
2 years, 1 = not sick in last 2 years, 2 = not 314. 0 1 2 3 Mucus producing cough
sick in last 4 years, 3 = not sick in last 7 years) 315. 0 1 2 3 Frequent colds or flu (0=1 or less per year, 1=2
318. 0 1 2 3 Acne (adult)
to 3 times per year, 2=4 to 5 times per year, 3=6 319. 0 1 2 3 Itchy skin (Dermatitis)
320. 0 1 2 3 Cysts, boils, rashes
316. 0 1 2 3 Other infections (sinus, ear, lung, skin, bladder,
321. 0 1 2 3 History of Epstein Bar, Mono, Herpes,
kidney, etc) (0=1 or less per year, 1=2 to 3 Shingles, Chronic Fatigue Syndrome, Hepatitis times per year, 2=4 to 5 times per year, 3=6 or or other chronic viral condition (0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = KEY: 0=No, symptom does not occur 2=Moderate symptom, occurs occasionally (weekly) 1=Yes, minor or mild symptom, rarely occurs (monthly) 3=Severe symptom, occurs frequently (daily)

Source: http://www.ccnmihc.ca/sites/ccnmihc.ca/files/practitioner_forms/langdon_nutritional_assessment.pdf