Nutritional Assessment

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Here we use our registration form on a secure server. All starred items must be filled in for the form to process. If the *items aren't filled in you cannot go on to the next pages.   *First Name   *Last Name    *Address    *City:    *State:    *Zip Code:    *Country:    *Email Address:    *Phone   Fax:  Amount of Payment is: $45.00. The fee covers the assessment process and the reports. VISA Master Card American Express    *Credit Card Type    *Credit Card Number:     *Name On Card:     *Expiration Date:  If you wish, you can print this form and mail it to us. Human Diamond Nutrition 1300 Browns Ct. Herndon, VA  22070 Medical History 1. Age:        2. Weight:          3. Height:          4. Male    Female  5. Married? Yes    No 6. Children? Yes    No        If yes, how many?        How old are they? 7. List your five main complaints: 8. What is your occupation? What kind of physical strain does your occupation produce in you? Is there anything you do not like about your job? 9. Please provide any pertinent information about surgeries, chronic diseases, illnesses, traumas, accidents, dental work, etc. 10. Please list all medications and supplements you are currently taking on a regular basis. Diet Assessment HOW MANY OF THESE FOODS DO YOU EAT PER WEEK? CARBOHYDRATES Times per Week Pasta   (all kinds--number of servings the size of your fist) Breads   (number of single servings--slice of bread, rice cake, cookie, piece of cake, etc.) Cereals   (breakfast and snacks--number of fist size servings) Candy, Chocolate, Sugar   (all kinds--pieces of candy and teaspoons of sugar) Dried Fruit   (figs, raisins, dates, etc.--number of single pieces) Grains   (wheat, millet, oatmeal, barley, corn, rye, rice etc.--number of fist size servings) Legumes   (beans (all kinds), garbanzo, lentils, peas, etc.--number of fist size servings) Vegetables   (green leafy vegetables and other colors--number of fist size servings) Fruit Juices   (all kinds--number of 4 oz servings) Fresh fruit   (all kinds--number of pieces) PROTEINS:   ANIMAL Times per Week Meats    (beef, lamb, pork, etc--number of servings) Poultry   (chicken, turkey, game birds, etc--number of servings) Fish and seafood   (number of servings) Eggs   (number of eggs) Dairy   (milk, yogurt, white fresh cheese--number of servings) PROTEINS:    VEGETABLE Times per Week Grains and Legumes together   (number of servings) Tofu   (partial protein- not all essential amino acid -- number of servings) FATS Times per Week Salad Oils   (store bought salad dressings -- tablespoons) Hydrogenated oils or partially hydrogenated oils like, Mazola   (tablespoons) Olive Oil   (tablespoons) Butter   (tablespoons) Spreads   (tablespoons) Nuts and Butter from nuts   (tablespoons) Grease cheeses   (number of ounces) STIMULANTS Times per Week Coffee, Tea   (caffeinated or decaffeinated--number of cups) Wine and Alcohol   (number of 2 oz servings) Fitness Evaluation Present level of fitness: Describe your average physical activity during the week? How often do you perform cardiovascular exercise? What is your preferred type of exercise? What is the approximate duration of each cardiovascular exercise? Do you check your heart rate during the exercises? How often do you weight train each week? Symptom Assessment Instructions:  Click the only boxes which apply to you. Select MILD for syptoms that occur once or twice a year, MODERATE for symptoms that occur several times a year, and SEVERE for symptons you are aware of almost constantly. GROUP I   Symptom Mild Moderate Severe 1. Acid foods upset 2. Get chilled, often 3. "Lump" in throat 4. Dry mouth-eyes-nose 5. Pulse speeds after meals 6. Keyed up-fail to calm 7. Cuts heal slowly 8. Gag easily 9. Unable to relax; startles easily 10. Extremities cold, clammy 11. Strong light irritates 12. Urine amount reduced 13. Heart pounds after retiring 14. "Nervous" stomach 15. Appetite reduced 16. Cold sweats often 17. Fever easily raised 18. Neuralgia-like pains 19. Staring, blinks little 20. Sour stomach frequent   GROUP II   Symptom Mild Moderate Severe 1.  Joint stiffness after arising 2. Muscle-leg-toe cramps at night 3. "Butterfly" stomach, cramps 4. Eyes or nose watery 5. Eyes blink often 6. Eyelids swollen, puffy 7. Indigestion soon after meals 8. Always seems hungry; feels "lightheaded" often 9. Digestion rapid 10. Vomiting frequent 11. Hoarseness frequent 12. Breathing irregular 13. Pulse slow; feels "irregular" 14. Gagging reflex slow 15. Difficulty swallowing 16. Constipation, diarrhea alternating 17. "Slow starter" 18. Get "chilled" infrequently 19. Perspire easily 20. Circulation poor, sensitive to cold 21. Subject to colds, asthma, bronchitis   GROUP III   Symptom Mild Moderate Severe 1. Eat when nervous 2. Excessive appetite 3. Hungry between meals 4. Irritable before meals 5. Get "shaky" if hungry 6. Fatigue, eating relieves 7. "Lightheaded" if meals delayed 8. Heart palpitates if meals missed or delayed 9. afternoon headaches 10. Overeating sweets upsets 11. Awaken after few hours sleep-hard to get back to sleep 12. Crave candy or coffee in afternoons 13. Moods of depression-"blue" or melancholy 14. Abnormal craving for sweets or snacks   GROUP IV   Symptom Mild Moderate Severe 1.  Hands and feet go to sleep easily, numbness 2. Sigh frequently, "air hunger" 3. Aware of "breathing heavily" 4. High altitude discomfort 5. Opens windows in closed room 6. Susceptible to colds and fevers 7. Afternoon "yawner" 8. Get "drowsy" often 9. Swollen ankles worse at night 10. Muscle cramps, worse during exercise; get "charley horses" 11. Shortness of breath on exertion 12. Dull pain in chest or radiating into left arm, worse on exertion 13. Bruise easily, "black/blue" spots 14. Tendency to anemia 15. "Nose bleeds" frequent 16. Noises in head or "ringing in ears" 17. Tension under the breastbone, or feeling of "tightness", worse on exertion   GROUP V   Symptom Mild Moderate Severe 1. Dizziness 2. Dry skin 3. Burning feet 4. Blurred vision 5. Itching skin and feet 6. Excessive falling hair 7. Frequent skin rashes 8. Bitter, metallic taste in mouth in mornings 9. Bowel movements painful or difficult 10. Worrier, feels insecure 11. Feeling queasy; headache over eyes 12. Greasy foods upset 13. Stools light-colored 14. Skin peels on foot soles 15. Pain between shoulder blades 16. Use Laxatives 17. Stools alternate from soft to watery 18. History of gallbladder attacks or gallstones 19. Sneezing attacks 20. Dreaming, Nightmare type bad Dreams 21. Bad breath (halitosis) 22. Milk products cause distress 23. Sensitive to hot weather 24. Burning or itching anus 23. Crave sweets   GROUP VI   Symptom Mild Moderate Severe 1. Loss of taste for meat 2. Lower bowel gas several hours after eating 3. Burning stomach sensations, eating relieves 4. Coated tongue 5. Pass large amounts of foul smelling gas 6. Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hours 7. Mucus colitis or "irritable bowel" 8. Gas shortly after eating 9. Stomach "bloating" after eating   GROUP VII   Symptom Mild Moderate Severe A 1. Insomnia 2. Nervousness 3. Can't gain weight 4. Intolerance to heat 5. Highly emotional 6. Flush easily 7. Night sweats 8. Thin, moist skin 9. Inward trembling 10. Heart palpitates 11. Increased appetite without weight gain 12. Pulse fast at rest 13. Eyelids and face twitch 14. Irritable and restless 15. Can't work under pressure B 16. Increase in weight 17. Decrease in appetite 18. Fatigue easily 19. Ringing in ears 20. Sleepy during day 21. Sensitive to cold 22. Dry or scaly skin 23. Constipation 24. Mental sluggishness 25. Hair coarse, falls out 26. Headaches upon arising wear off during day 27. Slow pulse, below 65 28. Frequency of urination 29. Impaired hearing 30. Reduced initiative C 31. Failing memory 32. Low blood pressure 33. Increased sex drive 34. Headaches "splitting or rending" type 35. Decreased sugar tolerance D 36. Abnormal thirst 37. Bloating of abdomen 38. Weight gain around hips or waist 39. Sex drive reduced or lacking 40. Tendency to ulcers, colitis 41. Increased Sugar Tolerance 42. Women: menstrual disorders 43. Young girls: lack of menstrual function E 44. Dizziness 45. Headaches 46. Hot flashes 47. Increased blood pressure 48. Hair growth on face or body (female) 49. Sugar in urine (not diabetes) 50. Masculine tendencies (female) F 51. Weakness, dizziness 52. Chronic fatigue 53. Low blood pressure 54. Nails weak, ridged 55. Tendency to hives 56.  Arthritic tendencies 57. Perspiration increase 58. Bowel disorders 59. Poor circulation 60. Swollen ankles 61. Crave salt 62. Brown spots or bronzing of skin 63. Allergies-tendency to asthma 64. Weakness after colds, influenza 65. Exhaustion-muscular and nervous 66. Respiratory disorder   FEMALE ONLY   Symptom Mild Moderate Severe 1. Very easily fatigued 2. Premenstrual tension 3. Painful menses 4. Depressed feelings before menstruation 5. Menstruation excessive and prolonged 6. Painful breasts 7. Menstruate too frequently 8. Vaginal discharge 9. Hysterectomy/ovaries removed 10. Menopausal hot flashes 11. Menses scanty or missed 12. Acne, worse at menses 13. Depression of long standing   MALE ONLY   Symptom Mild Moderate Severe 1. Prostate trouble 2. Urination difficult or dribbling 3. Night urination frequent 4. Depression 5. Pain on inside of legs or heels 6. Feeling of incomplete bowel evacuation 7. Lack of energy 8. Migrating aches and pains 9. Tire too easily 10. Avoids activity 11. Leg nervousness at night 12. Diminished sex drive

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