The Bolles Clinic The Leo J. Bolles Clinic
15611 Bel-Red Rd., Bellevue WA, 98008 (425)881-2224

Nutritional Assessment Questionnaire


Name:  
E-Mail:
Gender:  
Birthdate:

Please list your five major health concerns in order of importance:
 1  
 2  
 3  
 4  
 5  

PART I

Read the following questions and fill in the number that applies:

KEY:

0 (or leave blank) = Do not consume or use
1 = Consume or use 2-3 times/month

2 = Consume or use weekly
3 = Consume or use daily

DIET

  1. Alcohol
  2. Artificial sweeteners
  3. Candy or other sweets
  4. Carbonated beverages
  5. Chewing tobacco
  6. Cigarettes
  7. Cigars/pipes
  1. Coffee
  2. Eat fast food regularly
  3. Fried foods
  4. Luncheon meats/ hot dogs
  5. Margarine
  6. Milk products
  7. Non-herbal tea
  1. Refined flour/ Baked goods
  2. Refined sugar
  3. Vitamins and minerals
  4. Water, distilled
  5. Water, Tap
  6. Water, well
  7. Diet often

  1. Times you exercise per week (1 = once a week, 2 = 2-4 times/week, 3 = 5 times a week)
  2. Changed jobs (3= within last 2 months, 2= within last 6 months, 1= within last 12 months.)
  3. Divorced (3= within last 6 months, 2= within last year, 1= within last 2 years)
  4. Work over 60 hours/week (3= always, 2= usually, 1= occasionally, 0= never)

MEDICATIONS
Check any medications you're currently taking or have taken in the last month:

  1. Antacids
  2. Antibiotics
  3. Anticonvulsants
  4. Antidepressants
  5. Antifungals
  6. Aspirin/Ibuprofen
  1. Asthma inhalers
  2. Beta blockers
  3. Chemotherapy
  4. Cortisone
  5. Diabetic medications
  6. Diuretics
  1. Estrogen/Progesterone
  2. Heart medications
  3. High blood pressure
  4. Hormone Therapy
  5. Laxatives
  6. Insulin
  1. Oral/implant contraceptives
  2. Radiation exposure
  3. Recreational drugs
  4. Relaxants/Sleeping pills
  5. Thyroid medication
  6. Tylenol/acetaminophen
  7. Ulcer medications

LIFESTYLE

PART II

Read the following questions and fill in the number that applies:
(How significant is the symptom? How true is the statement? 0 means not at all, 3 means extremely true.)

KEY:

 0 (or leave blank) = No or Do not have the symptom, the symptom does not occur
1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)
2 = It is a moderate symptom or it occasionally occurs (weekly)
3 = It is a severe symptom or it frequently occurs (daily)

 Section 1

  1.  Belching or gas within 1 hr. of a meal
  2.  Heartburn or acid reflux
  3.  Bloating shortly after eating
  4.  Are you a vegan (no dairy, meat, fish or eggs)
  5.  Bad breath (halitosis)
  6.  Loss of taste for meat
  7.  Sweat has a strong odor
  8.  Stomach upset by taking vitamins
  9.  Sense of excess fullness after meals
  1.  Do you feel like skipping breakfast?
  2.  Do you feel better if you don’t eat?
  3.  Sleepy after meals
  4.  Fingernails chip, peel or break easily
  5.  Anemia unresponsive to iron
  6.  Stomach pains or cramps
  7.  Diarrhea, chronic
  8.  Diarrhea shortly after meals
  9.  Black or tarry stools
  10.  Undigested food in stool