The Quick Symptom Questionnaire*
--adapted from Julia Ross?s book ?The Diet Cure? 

This questionnaire is a quick way to identify many root causes of clinical conditions.  As a nutritionist, I use this as a springboard into developing an individualized action plan.  It also helps prioritize health issues, so that I can work effectively with each client:
 

Brain Chemistry                                                                Total Score ___________

4              Sensitivity to emotional (or physical) pain; cry easily
4              Eat as a reward for pleasure, comfort, numbness
4              Worry, anxiety, phobia or panic
4              Difficulty getting to sleep or staying asleep
3              Difficulty with focus, attention deficits
2              Low energy, drive and arousal
4              Obsessive thinking or behavior
4              Inability to relax after tension, stress
3              Depression, negativity
4              Low self esteem, lack of confidence
4              More mood and eating problems in winter or end of day
3              Irritability, anger
4              Use alcohol or drugs to improve mood

 If your score is over 10, your brain chemistry and neurotransmitters may be out of balance. A nutritionist can help you raise your serotonin levels naturally, and help you reduce the detrimental effects of emotional stress.

Low Calorie Dieting                                                          Total Score ________________

4              Increased cravings for and focus on food; overeating
4              Regain weight after dieting, more than was lost
3              Increased moodiness, irritability, anxiety, or depression
3              Less energy and endurance
3              Usually eat less than 2,100 calories/day
3              Skip meals, especially breakfast
3              Eat mostly low-fat carbs like bagels and pasta
2              Constantly think about weight
2              Use aspartame daily
2              Take Prozac or similar serotonin-boosting drugs
2              Have become vegetarian
3              Decreased self-esteem
4              Have become bulimic or anorectic

 If your score is over 12, your body may not be burning calories as fast as it could, due to low calorie intake. You may also be deficient in critical nutrients. Through counseling, a nutritionist will help educate you on why it?s important to NOT deprive yourself of food. 

Blood Sugar and Stress                                    Total Score ____________

 
4              Crave a lift from sweets or alcohol, but experience a drop in mood afterwards
4              Family history of diabetes, hypoglycemia, or alcoholism
3              Nervous, jittery, irritable, headachy or weak, on and off during the day. May be calmer after meals
3              Frequent infections, allergies or asthma, especially when weather changes
3              Mental confusion, decreased memory, hard to focus or get organized
4              Frequent thirst
3              Night sweats (not menopausal)
5              Light-headed, especially on standing up
4              Crave salty foods or licorice
4              Often feel stressed, overwhelmed and exhausted
4              Dark circles under eyes or eyes sensitive to bright ligh
4              More awake at night 

If your score is over 12, it?s important that you work on balancing blood sugar and bringing stress levels down. Testing can identify areas of opportunity to get you started on a nutrition plan.

Thyroid Function                                               Total Score __________________ 

4              Low energy
4              Easily chilled (especially hands and feet)
4              Other family members have thyroid problems
4              Can gain weight without overeating; hard to lose excess weight
3              Have to force yourself to do even moderate exercise
4              Find it hard to get going in the morning
3              High cholesterol
3              Low blood pressure
4              Weight gain began near the start of menses, a pregnancy, or menopause
3              Chronic headaches
3              Use food, caffeine, tobacco and /or other stimulants to get going 

If your score is over 15, you may need to get your thyroid checked. A nutritionist will show you ways to kick start your thyroid, for more energy, naturally. 

Female Hormones                                                             Total Score: _____________________

4              Premenstrual mood swings
4              Premenstrual or menopausal food cravings
4              Irregular periods or migraines
4              History of fibroids
3              Experienced miscarriage, abortion or infertility
4              Use(d) birth control pills or other hormone medication
3              Uncomfortable periods ? cramps, lengthy or heavy bleeding, or sore breasts
4              Peri- or postmenopausal discomfort (hot flashes, weight gains, sweats, insomnia or mental               dullness)
3              Skin eruptions with period 

If you scored is over 6 your hormones are out of balance. You may need a nutritional program that incorporates working with your doctor.
 

Food Allergies                                                                    Total Score ___________________ 

3              Crave milk, ice cream, yogurt, cheese, or doughy foods and eat them frequently
3              Experience bloating after meals
4              Gas, frequent belching
3              Digestive discomfort of any kind
3              Chronic constipation and/or diarrhea
4              Respiratory problems, such as asthma, postnasal drip, congestion
3              Low energy or drowsiness, especially after meals
4              Allergic to milk products or other common foods
3              Under-eat or often prefer beverages to solid foods
3              Avoid food or throw up food because bloating after eating makes you feel fat or tired
4              Can?t gain weight
3              Hyperactivity or manic depression
3              Severe headaches or migraine
4              Food allergies in family 

If your score is over 12, you may be addicted to foods you are actually allergic to. Simple tests and/or elimination diets can pinpoint the offending foods, and an elimination of them usually results in weight loss and increased energy.

Yeast                                                                                      Total Score: _____________

4              Often bloated abdominal distention
3              Foggy-headed
2              Depressed
4              Yeast Infections
4              Used antibiotics extensively (at any time in life)
4              Used cortisone or birth control pills for more than one year
4              Have chronic fungus on nails or skin or athlete?s foot
3              Recurring sinus or ear infections as an adult or child
3              Achy muscles and joints
4              Rashes
3              Stool unusual in color, shape or consistency 

If you scored over 13, you have a yeast problem, which a nutritionist can correct with changes in diet and natural nutritional therapies.

Fatty Acids                                                                           Total Score: _________________ 

4              Crave chips, cheese, and other rich foods more than, or in addition to sweets and starches
4              Have ancestry that includes Irish, Scottish, Welsh, Scandinavian or coastal Native American
3              Alcoholism and depression in the family history
3              High cholesterol, low HDL levels
4              Feel heavy, uncomfortable, and ?clogged up? after eating fatty foods
4              History of hepatitis or other liver or gallbladder problems
4              Light colored stools
4              Hard or foul-smelling stool
4              Pain on right side under rib cage 

If your score is over 12, you may have a fatty acid deficiency, which can be easily fixed with nutritional supplementation.