Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Special Instructions: To answer Question #30 requires that you first perform the 10-day Axillary Temperature Test, click here for instructions.

SECTION A: Colon/Bowel:
1. My bowels move: x day; x week (on the average).

2. Laxative use: x daily; x weekly; x monthly; never.
    Type used:

4. Do you have trouble initiating your bowel movement, yet the stool is not too large or too hard? Yes No

5. Does abdominal discomfort or cramping ever accompany bowel movements? Yes No
    How often?

6. Have you ever been diagnosed as having a stomach, liver, gallbladder, pancreas, intestinal or bowel disorder or disease? Yes No

    If yes, please explain.

7. Have you had or do you have hemorrhoids or varicose veins? Yes No Explain.

8. Do you make a conscious effort to eat a high fiber diet? Yes No What do you eat?

9. Do you usually pay attention when nature calls? Yes No

SECTION B: Kidney/Bladder:

10. Do you drink and cook with:
      Reverse Osmosis water Yes No At Times
      Distilled water Yes No At Times
      Filtered Water Yes No At Times

11. Do you drink tap water? No Well water Municipal

12. How much water do you consume daily?
      No. of Ounces or No. of Quarts

13. Do you feel satisfied that your bladder is completely empty after urinating? Yes No At Times

14. Do you have any burning or irritation during or after urination? Yes No At Times

15. Do you have difficulty starting or stopping when urinating? Yes No At Times

16. Do you get up in the middle of the night to urinate? Yes No At Times
      How often? x night; x week.

17. Does your urine have a strong odor to it? Yes No
      Is it usually: clear cloudy bright yellow dark yellow orange normal other other

18. At times it has been: cloudy orange red greenish brownish normal other other

19. Please list the number and nature of the beverages you drink daily and regularly.

20. Do you get recurrent bladder infections? Yes No At Times

21. Do you get unexplained deep lower back pains just below your ribs? Yes No At Times

SECTION C: Exercise:

22. Do you exercise regularly? Yes No
       x daily; x weekly; x monthly.

23. Please indicate the nature of the exercise and also the number of minutes per session.

24. Do you monitor your pulse while exercising? Yes No

      What is your resting pulse rate? beats per minute.

25. Do you perspire with your exercise? never lightly moderately heavily

26. Do you perspire other than when exercising? Yes No
       When?

27. Do you have difficulty perspiring? Yes No

28. Does your perspiration smell strong? Yes No Does it smell like urine? Yes No

29. Do you get short of breath with even slight exertion? Yes No

30. What is your basal temperature? (To answer #30, select the appropriate result from your 10-Day Axillary Temperature Test (ATT). If you have not completed the ATT, print your answers from 1-29, click here for the Axillary Temperature TestInstructions, and then return to complete this questionnaire after performing the Axillary Temperature Test.)(To obtain basal temperature, click here to go to.
What is your basal temperature after performing the 10-day Axilllary Temperature Test? 97.8 F or 36.5 C Below 97.8 F or 36.5 C Above 97.8 F or 36.5 C

31. Do you take regular saunas, steam baths or do cold friction rubs? Yes No

SECTION D: Occupational/Household:

32. What is your occupation?

     Please describe the work?

33. Do you work in an office building? Yes No How many hours per week?
      Do the windows open? Yes No

34. Do you have specialized air filtration at your work place? Yes No
      What type?

35. Do you work in the-presence of toxic fumes, or chemicals? Yes No
      Have you ever? Yes No
      Please provide details?

36. Do you smoke? Yes No

      How much do you smoke?

37. Are you exposed to second hand smoke? Yes No

38. Do you drink alcohol? Yes No
      What type do you drink?
39. How often do you drink alcohol? never daily weekly monthly

40. Do you use any type of drug (prescription or otherwise)? Yes No
     What type/types?

41. How often, what dosage and for what symptom?

      
42. Do any of your hobbies involve toxic materials? Yes No
      If so, what kind (paints, plastics, gases, etc.)?

43. Do you have specialized air filtration at home? Yes No
      What type?

44. Do you live in a city? Yes No

      How many hours do you spend outside per day? .25 (15 minutes) .50 (30 minutes) .75 (30 minutes) 1 hour 2 hours 3 hours More than 3 hours
      Per week? .25 (15 minutes) .50 (30 minutes) 1 hour 2 hours 3 hours More than 3 hours

45. Do you wear sunglasses, contact lenses or glasses when outside? sunglasses contact lenses glasses

46. Do you have any respiratory disorders, i.e., Sinusitis, Asthma, Emphysema, Bronchitis, etc.? Yes No Please explain.

47. Do you have house pets? Yes No What type?

SECTION E: Detoxification:

48. Have you ever conducted a detoxification program supervised by a qualified health professional? Yes No Please explain.

49. Do you fast? Yes No
      How often and for how long?

50. Are you on a special diet? Yes No Please explain.

51. If you avoid any foods or follow a special dietary program, please explain.

52. On the average night, what time do you go to bed?
      What time do you usually rise?
      How many hours do you sleep on the average night?

53. Do you feel well rested on awakening in the morning (ie. ready to rise and get at things)?
Yes No

54. Do you nap or rest horizontally through the day? Yes No
      If yes, for how long on the average?

55. On a scale of 1-10, how do you rate the quality of your sleep (1 being lousy and 10 being perfectly restful)?

Note: This questionnaire is strictly confidential between you and your Clinical Nutritionist. Your accurate responses are vital to effective health care at this office. Please go back over your responses and consider their accuracy. Thank-you!

Copyright 1991, New Health Perspectives, Inc.