Nutritional Deficiencies

Answer the questions below, using the symptom scale:

0=Never 1=Seldom 2=Occasionally 3=Frequently

4=Infrequently with severe symptoms 5=Almost always

Hypoglycaemia

Irritability

Seborrheic dermatitis

Cervical dysplasia (abnormal pap smear)

Phlebitis

Food allergies

Dry Skin

Acne

High blood cholesterol

Chemical Hypersensitvity

Premenstrual symptoms

Diarrhoea

Arteriosclerosis

Depression

Recurrent colds and respiratory infections

Poor night vision

Bruising

High blood pressure

Insomnia

Carpal tunnel syndrome

Heart rhythm disturbance (palpitations)

Infertility

Fatigue

Eczema

Gum disease

Arthritis

Spina bifida (birth defect attributed to nutritional deficiencies in pregnant women)

Excessive dietary hazards (refined carbohydrates, partially hydrogenated oils, phosphorous from soft drinks and flesh foods)

Please ensure all boxes are filled in with a number, or your report may be inaccurate.

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