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Nutritional Assessment
Questionnaire
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1
Name:
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Last Name
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2
E-mail
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3
Phone Number
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4
Do you have trouble either with either losing or gaining weight?
YES
NO
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5
Do you currently experience digestive distress?
YES
NO
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6
Which foods are you most reactive to?
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7
How many hours of sleep do you get per night?
>4
5
6
7
8+
>4
5
6
7
8+
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8
Do you have trouble either staying or falling asleep?
YES
NO
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9
Do you experience brain fog in the morning?
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NO
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10
Do you currently take nutritional supplements? If yes, which ones?
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11
How many times in the past 2 years have you been on antibiotics?
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12
What is your current stress level?
1
2
3
4
5
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13
What is your education level?
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14
What is your occupation?
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15
Were you referred to Molly Rose Health? Please tell us how you heard about us.
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