Nutritional Assessment Questionnaire

Fields marked with an * are required

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


Medications Indicate any medications you're currently taking  or have taken in the last month (0=no, 1=yes)

0=No, symptom does not occur
1=Yes, minor or mild symptom, rarely occurs (monthly)
2=moderate symptom, occurs occasionally (weekly)
3=Severe symptom, occurs frequently (daily)

Section 12 - Men only

Section 13 - Women only