NUTRITIONAL DEFICIENCY
** If any part of a question applies, score it: 1-Mild, 2-Moderate, 3-Severe
ENERGY AND STRESS RELIEF
B-COMPLEX FOOD SOURCES- wheat gem, whole grains, nuts, seeds, oats, eggs, beans, soy, brown rice, buckwheat, legumes
_____frequent fatigue
_____irritability
_____depression
_____craving for sweets, alcohol, coffee
_____fits of temper
_____hurt all over
_____heart palpitations
_____hair loss
_____digestive problems: gas, burping, bloating
_____high stress level
_____mood changes and anxiety attacks
_____cracks at corners of mouth
_____Carpal Tunnel Syndrome
_____PMS, excessive fluid retention
_____headaches
_____memory problems
_____interested in preventing heart disease
_____Hypoglycemic tendencies: emotional on an upset stomach,
shakiness, headaches, weak spells, dizziness, lack of concentration,
tired mid-afternoon
_____ Total B-Complex Score
PROTEIN FOOD SOURCES- nuts, meats, yogurt, cheese, eggs, whole grains, soy, fish, beans (legumes)
_____frequent fatigue
_____mood swings
_____irritability
_____weakness in general
_____poor muscle tone
_____dry, lifeless hair
_____slow wound healing
_____frequent colds, flu, or infections
_____splitting nails
_____cancer/prevention
_____menopausal symptoms
_____high cholesterol
_____hypoglycemic tendencies (see b-complex)
_____vegetarian diet
_____Total Protein Score
CALCIUM MAGNESIUM FOOD SOURCES - yogurt, organic milk, carob, collards, green and leafy vegetables, almonds, nuts, broccoli, oats, kale, kelp, cheese, apricots, apples
_____muscle cramps, tension
_____insomnia
_____foot or leg cramps
_____frequent backache
_____headaches
_____arthritis, joint pain
_____irregular heartbeat
_____osteoporosis
_____PMS, menopause
_____susceptibility to bone fractures
_____consume less than 3 servings a day of yogurt, organic milk, organic cheese
_____tooth grinding
_____anxiety, fear, nervousness
_____ TOTAL CALCIUM MAGNESIUM SCORE
ANTIOXIDANTS
CAROTENOIDS - BETA-CAROTENE FOOD SOURCES - spinach, peaches, sweet potatoes, pumpkin, squash, kale, beets, broccoli, apricots, turnip greens, carrots, cantaloupe
_____acne, blackheads, warts
_____poor night vision
_____macular degeneration
_____prostate problems
_____cervical abnormalities
_____lung disease
_____asthma
_____emphysema
_____history of bronchitis or pneumonia
_____cataracts and/or glaucoma
_____aging spots on skin
_____history of cancer
_____"goose bumps" on back of arms
_____want to prevent cancer
_____dry, rough skin
_____do not eat 3-5 servings of vegetables and fruits per day
_____frequent illness
_____weak immune system
_____current or past smoker
_____history of heart disease
_____want to prevent heart disease
_____ TOTAL CAROTENOIDS SCORE
VITAMIN C FOOD SOURCES - lemons, oranges, plums, mangoes, cantaloupes, pineapples, tomatoes,radishes, peas, collards, grapes, strawberries, grapefruit, onions, sweet peppers,
_____bleeding gums/ mouth & gum disease
_____smoke cigarettes
_____varicose veins/ broken capillaries
_____frequent colds or flu
_____bruise easily
_____hangnails, cuticles tear easily
_____nosebleeds
_____slow healing of wounds or fractures
_____allergies, asthma, bronchitis
_____arthritis
_____history of cancer
_____high cholesterol/ heart conditions
_____high level of stress
_____eat less than 2 servings of fruit daily
_____eat less than 3 servings of veggies daily
_____deteriorating joints/ stiff joints
_____anemia
_____deficient lactation
_____low resistance to infections
_____excessive hair loss
_____ TOTAL VITAMIN C SCORE
VITAMIN E & SELENIUM FOOD SOURCES - brown rice, nuts, eggs, cornmeal, oatmeal, beans, green leafy veggies, wheat germ, cold-pressed oils
_____heart conditions
_____shortness of breath on exertion
_____hot flashes
_____diminished sex drive
_____breast tenderness
_____fibrocystic disorders, cystic conditions
_____cold hands & feet
_____poor circulation/numbness in arms or legs
_____psoriasis
_____leg pain
_____low exercise tolerance
_____hormonal imbalances
_____high blood pressure
_____history of tumors
_____scar formation
_____blood clots
_____excessive exposure to sunlight, x-rays, & other forms of radiation
_____history of miscarriages
_____sterility
_____eat fried & processed foods
_____aging spots on skin/premature aging
_____cancer/interested in preventing
_____HIV virus
_____ Total Vitamin E & Selenium Score
Co-Q 10 FOOD SOURCES - avocadoes, soy, spinach, mackerel, salmon, sardines
_____fatigue
_____shortness of breath
_____low exercise tolerance
_____poor circulation
_____chest pain or tightness
_____fluid retention in legs or feet
_____heart disease
_____congestive heart failure
_____high LDL cholesterol
_____on cholesterol lowering medication
_____irregular heartbeat of rhythm
_____Parkinson's, or Huntington's disease
_____overweight
_____slow metabolic rate
_____middle age or older
_____ TOTAL COENZYME Q 10
FLAVONOIDS: FOOD SOURCES - bilberries, blueberries, onions, apples, broccoli, tomatoes, soy beans, green tea, cherries, red cabbage, carrots, limes
_____weak immune system
_____bruising
_____varicose veins
_____hemorrhoids
_____asthma
_____allergies
_____sinus problems
_____eczema
_____psoriasis
_____hives
_____cataracts
_____ulcerative colitis
_____prevention of cancer
_____gout
_____inflammation
_____osteoporosis
_____toxic household
_____TOTAL FLAVONOIDS SCORE
CLEANSING NUTRIENTS - ALFALFA
_____allergies
_____bad breath
_____asthma
_____puffy eyes
_____joint pains
_____swollen ankles and feet
_____arthritis
_____difficult or painful urination
_____digestive problems: gas, bloating, burping
_____body odor
_____excessive fluid retention
_____smelly feet
_____kidney or bladder infections
_____hiatal hernia
_____sinus problems
_____Diabetes
_____colon problems
_____constipation
_____TOTAL ALFALFA SCORE
PROBIOTICS FOOD SOURCE - yogurt, kefir, cultured dairy, miso, sauerkraut, tempeh
_____antibiotic usage
_____birth control pills or steroids
_____mood swings & irritability
_____cravings for sweets, breads & alcohol
_____problems in moldy areas or on muggy days
_____sensitivity to perfumes, chemical odors, etc.
_____being really bothered by tobacco smoke
_____athlete's foot, fungus infections on nails & skin
_____repeated pregnancies
In Infants:
_____diaper rash that is worse in the skin folds
_____thrush or white patches on the inner cheeks of mouth
_____a white-coated tongue
_____excessive genital touching
_____frequent ear infections
In Children:
_____thickly-coated or patchy, white tongue
_____red ring around the anus or rectal area
_____itchy genital area leading to frequent touching
_____chronic hair or foot odor
_____bloated abdomen and bowel complaints
_____frequent infections, particularly of the ears & tonsils
_____muscle aches and/or weakness
In Adolescents & Adults:
_____frequent fatigue, lethargy & drowsiness
_____frequent infections
_____frequent feelings of "spaciness"
_____poor memory
_____inability to make decisions
_____bloating, belching, or intestinal gas
_____muscle aches and/or weakness
_____recurrent skin problems
_____pain and/or swelling in joints
_____depression
_____abdominal pain
_____loss of interest in sex
_____Endometriosis or infertility
_____Prostatitis or impotence
_____anxiety attacks or frequent crying
_____PMS
_____mucus in stools
_____rectal itching
_____constipation and/or diarrhea
_____pelvic pain
_____burning or white coated tongue
_____blurred vision
_____spots in front of eyes
_____rash/blisters in mouth
_____excessive vaginal discharge/itching
_____dizziness/loss of balance/in coordination
_____pain or tightness in chest
_____TOTAL PROBIOTICS SCORE
GARLIC: FRESH GARLIC CRUSHED
_____throat and ear infections
_____frequent diarrhea, dysentery
_____fungal infections
_____high cholesterol & triglycerides
_____blood clots
_____indigestion
_____allergies
_____sinus infections
_____ulcers
_____colitis
_____repeated viral infections
_____recurrent bacterial infections
_____infected wounds
_____history of bronchitis
_____frequent sore throats
_____history of cancer
_____heavy metal toxicity
_____Candida infections
_____excessive fluid retention
_____premature aging
_____prevention of cancer
_____lowered immune system
_____TOTAL GARLIC SCORE
HERBAL PRODUCTS
SAW PALMETTO
_____enlarged prostate glands
_____decreased urinary output
_____frequent urination
_____urinary tract infections
_____lack of interest in sex
_____impotence
_____stress and tension
_____sterility
_____asthma
_____bronchitis
_____colds & congestion
_____dysmenorrhea
_____water retention
_____TOTAL SAW PALMETTO SCORE
VALERIAN
_____insomnia
_____muscle tension
_____stress
_____over-excitability
_____hysteria
_____stomach cramps
_____intestinal colic
_____gas pains
_____migraine headaches
_____rheumatic pain
_____TOTAL VALERIAN SCORE
IRON FOOD SOURCES - eggs, fish, green leafy veggies, whole grains, almonds, avocadoes, beets, molasses, peaches, pears
_____anemia
_____heavy menstrual bleeding
_____excessive fatigue
_____very pale skin
_____dizziness
_____nervousness
_____slowed mental reactions
_____ TOTAL IRON SCORE
ZINC FOOD SOURCES - egg yolks, fish, kelp, legumes, mushrooms, pecans, pumpkin seeds, soy lecithin, sunflower seeds
_____poor sense of smell
_____white spots on fingernails
_____dandruff
_____acne, especially teenage acne
_____perspire heavily or often
_____chronic colds and flu
_____slow healing of wounds
_____white-coated tongue
_____taking estrogen
_____thinning hair
_____prostate problems
_____fertility problems
_____Diabetes
_____anorexia
_____high levels of stress
_____TOTAL ZINC SCORE
Sources:
Gemma Gorham, M.P.H. 2002
Prescription for Nutritional Healing, Balch 2006
