Vitamin & Minerals

Vitamin & Mineral Questionnaire

Changes in a vitamins & minerals can begin anytime and be related to insufficient intake and or digestive concerns.  The imbalance of vitamins & minerals may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.
This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your degree of overall health risk.  It is not a substitute for professional medical advice from your health care provider.

Indicate with a check mark which circumstances apply to you now.  If they are not now present, but were previously, mark P.

SECTION I SECTION 9 Frequent tooth decay
Inability of eyes to adjust to darkness Early greying of hair Consume more than 3 soft drinks per week
See poorly in dim light Inflammation of the tongue Female: stopped having menses cycles
Eyeballs have lost luster;vision impaired; eyes dry or inflamed Changes in bowl movements Nails that are brittle or have longitudinal ridges
Skin is rough, scaly & dry, especially the elbows, knees & buttocks Easily fatigued TOTAL SECTION 18

Calcium ( 2)
Unable to distinguish yellow & blue Chronic fatigue SECTION 19
Eyelids “glued “together especially in the morning Shortness of breath High cholesterol
Loss of sense of smell Cleft palate Diabetes
Loss of appetite or desire to eat Spells of dizziness Alcohol intolerance
Skin blemishes,including “ liver spots” & skin rashes Macrocytic anemia TOTAL SECTION 19

Chromium(1)
Frequent infections of throat or lungs Use of birth control pill for more than 6 months SECTION 20
Frequent urinary tract infections or bladder Greyish-brown pigmentation of skin especially the face Weak hair & nails
Dryness of scalp( dandruff) TOTAL SECTION 9

Folic Acid(1)

 Fungus infections of nails
Dryness ofnose & throat SECTION 10 Eyes sensitive to light
Brittle nails Muscular weakness TOTAL SECTION 20

Copper(1)
Ridges in nails Generally fatigued SECTION 21
Frequent spells of fatigue Loss of appetite or desire for food Anemic
Frequent spells of diarrhea Frequent indigestion & or diarrhea Fingernails pale in colour
Loss of hearing Red skin on nose ,under eyes Dizzy spells
Known gall stones Bad breath Tire easily or chronic fatigue
Known kidney stones Frequent canker sores Difficulty breathing
Recurrent styes in eye Can’t get to sleep or stay asleep Shortness of breath
Frequently work in brightly lit area Hand & or feet go numb Cry easily without reason
Frequently work in dimly lit area Irritable , easily upset Poor appetite
Female: difficulty becoming pregnant Hands or feet feel hot Fingernails appear flat & brittle
Female: miscarriage Recurring headaches Pain in the heels
Ulcers Subject to constant stress, strain , tension Pain in the fingertips
Allergies Deeply depressed Rapid heart beat
Canker Sores Loss of memory Shoulder joints are painful
Subject to constant strain, stress, tension Dry scaly patches where skin is exposed to light Sleepy in daytime, sleepless at night
SECTION 1 TOTAL

Vitamin  A ( 7)

 Burning sensation of tongue Sensation of spots before eyes
Tongue is dark red, swollen or has cracks or   mouth is sore Constipation
SECTION 2 Chronic skin inflammation TOTAL SECTION 21

Iron(4)
Twitching of eye muscle Desire for alcohol SECTION 22
Swelling around eyes TOTAL SECTION 10

Vitamin B3(Niacin)

 Feeling of apprehension
Frequent blood shot eyes SECTION 11 Easily irritable
Fatigue easily or abnormally tired Sulfa therapy. Sore tongue
Loss of appetite or desire to eat Extreme fatigue. Cracks or sores at the corner of the mouth
Easily upset & irritable Anemia. Spoon or concave shaped nails
Loss of strength in lower arms & legs Irritability Suffer from frequent infections?
Hurt all over but can’t pinpoint why Depression Twitching muscles
Tenderness of calf muscles Nervousness Loose or sore teeth
Confusion & Forgetfullness Headaches Tremors of the hands
Stomach upset or pain Constipation Irregular pulse or heart beat
Constipation Early greying of hair Constantly cold
Diastolic blood pressure over 90 TOTAL SECTION 11

PABA (2)

 Muscular weakness
Irregularities in heart beat SECTION 12 Frequent muscle cramps
Enlarged heart Subject to constant stress, pressure, tension Have convulsions or seizures
Delayed or slow reflexes Chronic headaches Easily confused
Prickling sensation in lower extremeties Physically feel weak Dimmed vision
TOTAL SECTION 2

Vitamin B1 ( Thiamine) ( 4)

 Abnormally tired Feeling disoriented
SECTION 3 Frequent colds or upper respiratory infections Feeling depressed frequently
Cracks & sores in the corner of the mouth Suddenly feel dizzy TOTAL SECTION 22

Magnesium(3)
Red sore tongue Physically & or mentally overworked or overactive SECTION 23
Tongue shiney Feel  lightheaded when getting up or standing up Poor muscle coordination
Feeling of grit or sand in eyes Loss of feeling in hands & feet Prone to athletic injuries
Eyes tire easily Suffer from allergies As a child had partial paralysis of unknown cause
Burning or itching of eyes Frequent gastric distress As a child, had poor & or failing eyesight
Eyes sensitive to light Have periods of deep depression As a child, had poor & or failing hearing
See many blood vessels in whites of eyes Abdominal cramps or pain Have myasthenia gravis or multiple sclerosis
Frequent sores on lips Chronic consitpation Diagnosed as diabetic
Female: Itching in Vaginal Area Low blood sugar( hypoglycaemia) Allergies
Male: Itching of scrotum Arthritis Attacks of dizziness
Swelling or feeling of swelling tongue Attacks of vomiting Bone deformities
Muscle cramps in lower legs & feet TOTAL SECTION 12

Vitamin B5(Pantothenic Acid)(4)

 Noises in the ears
Scaling around nose, mouth, forehead & ears SECTION 13 TOTAL SECTION 23

Manganese(3)
“Whiteheads”especially on bridge of nose & under eyelids Anemia SECTION 24
Spells of dizziness Bleeding or inflamed gums Pyorrhoea( inflammation of gums & teeth)
Oily skin & or hair Easy bruising Mentally or physically fatigued
Excessive watering of eyes Small red or pink spots just under skin Often feel that breathing is irregular
Cataracts Susceptible to infections, including colds TOTAL SECTION 24

Phosphorus(1)
Lack of stamina & vigour Shortness of breath SECTION 25
Unexplained loss of weight Swollen or painful joints Swelling of the ankles
TOTAL SECTION 3

Vitamin B2(Riboflavin)(5)

 Frequent nose bleeds Occasional rapid heart beat for no reason
SECTION 4 Smoke Feel as if muscles are too weak
Ringing in ears Ruptured blood vessel in either eye Have irregular heart beat
Sore lips, mouth , tongue Joint pain that comes &  goes Diabetic
Loss of hair or thinning Known metal poisoning Prefer meat to vegetables & grains
Numbness & cramps in arms & or legs History of severe burns including sunburn Prefer summer to winter
Muscular weakness TOTAL SECTION 13

Vitamin C(3)

 Prefer seaside to mountains
Nausea or dizziness SECTION 14 Skin of face is more red than white
Nervous, irritable or depression Burning sensation in mouth & throat Body disorders are usually on right side
Confused often Weight loss or loss of appetite TOTAL SECTION 25

Potassium(2)
Painful joints of fingers & hands Vision problems SECTION 26
Swelling of hands, feet & ankles Unusual heart beat Have or had cancer
Increase in urination Poor bone development Family history of cancer
Known low blood sugar Muscular numbness, tingling or spasms You or your children have birth defects ?
Convulsions Rickets ( bowlegs, knock-knees, bone enlargements) Do you use diuretic drugs or water pills?
Fainting spells Flabby tissues Frequent diarrhea
Birth Control use greater than 6 months Dull pains in lower back & thighs TOTAL SECTION 26

Selenium(2)
Eczema Have you had an abnormal number of cavities? SECTION 27
Frequent tooth decay Deep pains in the legs ( bone pains or aches) Have dry tongue & shrunken loose skin( dehydration)
Kidney stones Osteomalacia ( softening of the bones) Feel exhausted all the time
High cholesterol Vague aches & pains Prefer vegetables & starches to protein ( meat)
Juvenile acne Arthritis Prefer winter to summer
Diarrhea Soreness or tenderness in ribs or breast bone Prefer mountains to seaside
Urine slightly greenish tint Stomach or gastric ulcers or diarrhea Skin of face is more white than red
Burning sensation on feet TOTAL SECTION 14

Vitamin D (5)

 Body disorders are usually on left side
TOTAL SECTION 4

Vitamin B6(Pyridoxine)(5)

 SECTION 15 SECTION 27

Sodium( 2)
SECTION 5 Have now or had “disc” problems ( slipped disc in spine) SECTION 28
Anemia Changes in heart rate ( fast or slow) Skin blemishes or dry, scaly skin
Soreness or weakness in arms & legs Known heart weakness or problem Wounds heal slowly
Arm & shoulder pain Female: one or more miscarriages Loss part of sense of smell
Shooting pains Use mineral oil for laxative purposes or digestion problems or malabsorption Lost part of sense of taste
Loss of appetite or desire to eat Have seen “ fat” in your stool Diabetic
Sore tongue Known gall bladder trouble Feel more tired than ususal
General muscular weakness Known colon trouble “ colitis” Acne
Inability to concentrate Impaired circulation ( cold spots or patchy skin) Male: prostatitis
Painful facial muscles Male: known sterility or loss of sex drive White spots on nails
Hot & cold sensations Female: menstrual discomfort  ( PMS) or hotflashes TOTAL SECTION 28

Zinc(2)
Feel like you have lost your incentive in life Varicose veins SECTION 29
Difficulty walking ( stumbling, shuffling) Chest pains & or pain in left arm Feeling coldness even in warm weather
Stammer occasionally History of blood clot Known low blood pressure
Jerking sensation in limbs History of phlebitis( inflamed veins) Tendency to gain weight easily
TOTAL SECTION 5

Vitamin B12( Cyanocobalamin ( 3)

 TOTAL SECTION 15

Vitamin E ( 3)

 Dull pain under the shoulder blades
SECTION 6 SECTION 16 Sluggish metabolism
Tongue often sore Brittle or lustreless hair Dry hair
Often skin inflammations Finger or toe nails break, peel, crack, brittle Brittle nails
Insomnia Allergies Eyes sensitive to bright light
Poor appetite Underweight & can’t gain Recurrent styes
Frequently nauseated Skin disorders High cholesterol
TOTAL SECTION 6

Biotin(1)

 Frequent attacks of diarrhea Decreased sexual interest
SECTION 7 Dandruff Dull headaches
Eczema Known to have kidney trouble Swelling of the eyes, hands & feet
Arteriosclerosis SECTION 17 Goiter ( Enlarged Thyroid)
High cholesterol Intestinal malabsorption or digestion problems Alternating fast & slow pulse
High blood pressure Known colitis ( colon irritation or inflammation) TOTAL SECTION 29

Iodine(3)
TOTAL SECTION 7

Choline(1)

 Cuts  or gums bleed easily and or a long time SECTION 30
SECTION 8 Have had need of long term antibiotic therapy

( knocks out intestinal flora)

 Indigestion
Muscle pains Gall bladder disease or difficulty digesting fatty foods Excessive belching &intestinal gas
Poor appetite Suffer in hot weather
Dry & peeling skin Do you overbreathe? ( hyperventilate)
Lack of energy Nervous without obvious cause
Sleeplessness TOTAL SECTION 17 Have diabetes or tendency?
Redness or inflammation of the skin SECTION 18 Are you on a low salt diet?
Mental depression Numbness & or tingling in arms & legs TOTAL SECTION 30

Chloride(2)
Have used sulfa drugs or antibiotics more than once in the last 5 years Frequent muscle cramps SECTION 31
Bloated Vague pains in joints Lackluster hair
Flatulence ( gas) Heart palpations ( irregular beats) Hair that falls out easily
Loss of desire for meat Slow pulse rate Enlarged parotid glands
Hungry at the start of a meal but can eat very little Can’t get to sleep or stay asleep Impaired wound healing
Known to have blood in the urine Female: menstrual cramps Edema
Overweight Trembling fingers Decreased muscle mass
TOTAL SECTION 8

Lipotrophic Factor ( 3)

 Dull back ache Fatigue
TOTAL SECTION 31

Protein (2)

Weight lbsX2.2/.8=Day

If you have 3 or more Y answers you may be at risk for vitamin & mineral concerns  .

It is recommended to consult with your health care professional team.

To book an appointment.



 
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