NSP Subquestionnaire

Client Alias *

The Digestive System

Underactive Stomach *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Excessive gas, belching or burping after meals

Stomach bloated after eating

Sleepy after eating

Longitudinal striations on fingernails

Eat when rushed/ in a hurry

Halitosis

Full feeling after heavy meat meal

Heavy, tired feeling after eating

Nausea after taking supplements

Acne

Undigested food in stool

Liver *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Yellow or pale fingernails

Skin oily on nose and forehead

Fats/ greasy foods cause nausea, headaches

Vertical white streaks on fingernails

Onions, cabbage, radishes, cucumbers cause bloating/gas

Bad breath; bad tastes in mouth

Excess body odor

High cholesterol/ high cholesterol diet

Migraine headaches

Discomfort underneath right ribcage

Food allergies

Irritable, easily angered

Weight gain around the abdomen

Yellow palms

Jaundice

Poor concentration

Difficulty losing weight

Acne, boils, rashes, psoriasis or eczema

Constipation

1

2

3

N/A

Yellow or pale fingernails

Skin oily on nose and forehead

Fats/ greasy foods cause nausea, headaches

Vertical white streaks on fingernails

Onions, cabbage, radishes, cucumbers cause bloating/gas

Bad breath; bad tastes in mouth

Excess body odor

High cholesterol/ high cholesterol diet

Migraine headaches

Discomfort underneath right ribcage

Food allergies

Irritable, easily angered

Weight gain around the abdomen

Yellow palms

Jaundice

Poor concentration

Difficulty losing weight

Acne, boils, rashes, psoriasis or eczema

Constipation

Gall Bladder *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Gall stones; history of gall stones

Stool appears clay-colored, foul odored

Constipation

High cholesterol diet; high blood cholesterol levels

Severe pain in right upper abdomen

Overactive Stomach *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Stomach pain 1 hour after eating or at night

Burning sensation in stomach

Pain aggravated by worry/ tension

Hiatal hernia

Gastritis, gastric ulcer

Nausea, vomiting

Sensation of acidity in abdominal area

Heartburn, indigestion

Blood in stool

Lower back pain

Long term aspirin use

Pancreas *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Severe abdominal pain

Nausea and vomiting

Slow digestion; feel full for hours after eating

Fever

Alcohol addiction

Jaundice

Dysglycemia *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Hungry up to 3 hours after eating

Strong, sudden cravings for sweets, starches coffee or alcohol

Nervous/ anxious feelings relieved by eating

Irritable if late for or if you skip a meal

Overweight

Addicted to coffee with sugar and/ or colas

Frequent "midnight snacks"

Family history of diabetes

Fatigue

Frequent headaches

Fainting spells

Depression

Lose temper easily

Candidiasis *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Extreme fatigue

Recurrent vaginal infections

Frequent use of antibiotics

White coated tongue, oral thrush

Crave sugars, bread, alcohol

Headaches

Tonsillitis, recurrent strep throat

Itchy, watery or dry eyes

Skin flushes

Chronic indigestion, frequently use antacids

Always cold, especially in extremities

Female: PMS

Pain in pelvic area

Abdominal gas and bloating

Loss of sex drive

Cystitis, repeated bladder infection

Increasing food and chemical sensitivities

Female: Emdometriosis/ ovary problems

Chronic diarrhea

Hives, psoriasis, acne, skin rashes

Rectal itching

Abnormal muscle aches from exercise

Excessive wax in ears

Unexpected/ unexplained weight gain

Impotence

Canker sores

Athlete's foot, finer/toenail fungus, ringwork

Jock itch

"Brain fog"

Irritability

Memory loss

Mental confusion

Depression or anger for no reason

Anxiety/ panic attacks

Inability to concentrate

Phobic/ compulsive

Lethargy

Mood swings

Itchy ears, nose, anus

1

2

3

N/A

Extreme fatigue

Recurrent vaginal infections

Frequent use of antibiotics

White coated tongue, oral thrush

Crave sugars, bread, alcohol

Headaches

Tonsillitis, recurrent strep throat

Itchy, watery or dry eyes

Skin flushes

Chronic indigestion, frequently use antacids

Always cold, especially in extremities

Female: PMS

Pain in pelvic area

Abdominal gas and bloating

Loss of sex drive

Cystitis, repeated bladder infection

Increasing food and chemical sensitivities

Female: Emdometriosis/ ovary problems

Chronic diarrhea

Hives, psoriasis, acne, skin rashes

Rectal itching

Abnormal muscle aches from exercise

Excessive wax in ears

Unexpected/ unexplained weight gain

Impotence

Canker sores

Athlete's foot, finer/toenail fungus, ringwork

Jock itch

"Brain fog"

Irritability

Memory loss

Mental confusion

Depression or anger for no reason

Anxiety/ panic attacks

Inability to concentrate

Phobic/ compulsive

Lethargy

Mood swings

Itchy ears, nose, anus

Parasites *

Please choose to which extent the items below apply to you. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring.

1

2

3

N/A

Forgetfulness

Slow reflexes

Gas and bloating

Unclear thinking

Loss of appetite

Yellowish or pale face

Fast heartbeat

Heart pain

Pain in navel

Eating more than normal but still feeling hungry

Blurry or unclear vision

Pain in the back, thighs, shoulders

Numb hands

Drooling while sleeping

Damp lips at night

Dry lips during the day

Grind teeth while asleep

Bedwetting

Lethargy; chronic fatigue

Dark circle under eyes

Cancer

1

2

3

N/A

Forgetfulness

Slow reflexes

Gas and bloating

Unclear thinking

Loss of appetite

Yellowish or pale face

Fast heartbeat

Heart pain

Pain in navel

Eating more than normal but still feeling hungry

Blurry or unclear vision

Pain in the back, thighs, shoulders

Numb hands

Drooling while sleeping

Damp lips at night

Dry lips during the day

Grind teeth while asleep

Bedwetting

Lethargy; chronic fatigue

Dark circle under eyes

Cancer