NSP Form Evaluation NSP Form Thank you for filling out the NSP form which accompanies the Lifestyle Assessment for Holistic Nutrition consultation. Full Name First Name Last Name Email: Age: If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Please Complete this Section: 1 2 3 General fatigue or weakness Difficulty losing weight Frequent illness/infections High stress lifestyle Smoking Drinking more than 2 cups of coffee/day Bad breath and/or body odor Constipation Bags under eyes Crave sugars, bread, alcohol Difficulty digesting certain foods Have used antibiotics in past 10 years Allergies Poor concentration or memory Belching or burping after meals Skin/complexion problems Frequent consumption of red meat Regular use of dairy products Heavy alcohol consumption Exposure to toxins/chemicals Frequent mood swings Depressed and/or irritable Brittle fingernails Dry, brittle hair, split ends High fat/high cholesterol diet Nervousness/anxiety/tension/worry Insomnia/restless sleep Low fiber diet Muscle cramps Sleepy when sitting up Female: menstrual cramps Bronchitis/asthma/pneumonoia/emphysema Cellulite Cold hands and feet Varicose veins Feeling out of control Food/chemical sensitivities Frequent yeast/fungus problems Bones break easily, osteoporosis Too little exercise Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Please complete this section: 1 2 3 Excessive mucus Short of breath climbing stairs Tingling in lips, fingers, arms, legs Chest pains Very rapid or slow heart beat Painful, hard, or thin bowel movements Alternating constipation/diarrhea Recurrent bladder infections Female: Menopause, hot flashes Female: PMS Difficult urination Swollen glands, puffy throat Lower abdominal pain Frequent need to urinate Joint pain Sinus inflammation/discharge Arthritis Sudden weight gain/loss Headaches/Migraines Female: Taking birth control pills Lower back pains Dry, flaky skin Drink less than 6 glasses of fluids/day Water retention Low sex drive Feeling heavy/bloated after meals Chronic cough The Digestive System Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Underactive Stomach 1 2 3 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 the stood Liver 1 2 3 Yellow or pale fingernails Skin oily on nose and forehead Fats/greasy foods cause nausea, headache Vertical white streaks on fingernails Onions, cabbage, radishes, cucumbers cause bloating/gas Bad breath; bad taste in mouth Excess body odour 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 1 2 3 Gall stones; history of gall stones Stool appears clay-colored, foul odoured Constipation High cholesterol diet; High blood cholesterol levels Severe pain in right upper abdomen Overactive Stomach 1 2 3 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 1 2 3 Severe abdominal pain Nausea and vomiting Slow digestion; feel full for hours after eating Fever Alcohol addiction Jaundice Dysglycemia 1 2 3 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 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 The Intestinal System Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Candidiasis 1 2 3 Extreme fatigue Recurrent vaginal infections Frequent use of antibiotics White coated tongue, oral thrush Crave sugars, bread, alcohol Headaches Tonsilitis, recurrent strep throat Itchy, watery or dry eyes Skin flushes Chronic indigestion, frequently use antacids Always cold, especially in extremities F: PMS Pain in pelvic area Abdominal gas and bloating Loss of sex drive Cystitis, repeated bladder infection Increasing food and chemical sensitivities; severe reaction to F: Endometriosis/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, finger/toenail fungus, ringworm 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 Parasites 1 2 3 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 circles under eyes Cancer Itchy ears, nose, anus The Lymphatic System Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Thymus (Immunity) 1 2 3 Excessive sleep Very susceptible to infections Swollen glands: tonsils, throat, armpits History of cancer, MS, Parkinson’s, Arthritis Loss of appetite Headaches Soreness on both sides of neck at shoulder Feel puffiness in throat Look older than chronological age Flu-like symptoms often occur Lupus Allergies 1 2 3 Acne, psoriasis, dermatitis, eczema Rapid pulse, heart irregularities Frequent headaches Hay fever Frequent cravings for certain foods Periods of blurred vision Repeated ear trouble Hyperactivity Dizzy spells Periods of confusion Poor concentration Epilepsy Muscle cramps or spasms Abnormal body odor Excessive sweating, night sweats Bowel disease: IBS, IBD, Crohn’s, etc. Join pains or stiffness Frequent night urination Wheezing Pale face Hives Nose runs constantly Noticeable changes in writing throughout day Nosebleeds Bloating or gas after eating certain foods Canker sores Dark circles under eyes Stuffy nose The Glandular / Endocrine System Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Underactive Thyroid / Hypothyroid 1 2 3 Distinct, lethargic tiredness or sluggishness Cold hands or feet Mercury amalgams (fillings) Gain weight easily, fail to lose on diets Constipation, less than one bowel movement a day Low energy in the morning Low pulse rate Low body temperature, especially bed rest Hair dry, brittle, dull, lifeless Flaky, dry rough skin Feel stiff after sitting still for some time Mood swings Usually square and wide fingernails High Cholesterol Pituitary 1 2 3 Infertility or impotence Headaches affecting one side of head F: loss of menstrual function Moody Overweight from waist down Overweight from waist up Excessive urination Pain in little finger of left hand Swelling in ankles, fingers and/or feet Cold hands or feet Pain in left side of upper neck Overactive Thyroid/Hyperthyroid 1 2 3 Losing weight without trying Heart races while at rest Feel warm/flushed at room temperature Hands shake or tremble Protruding tongue Heart palpitations Nervous behavior, hyperactivity Insomnia Increased appetite Frequent bowel movements, diarrhea Excessive sweating without exercise Adrenals 1 2 3 Stress or emotional upsets cause exhaustion Blood pressure decreases when going from a sitting to standing position Perspire excessively Neck and/or shoulder tension Frequent headaches Bow lines (depressed furrows on fingernails) Occasional cold sweats Tightness or lump in throat, especially when emotionally disturbed High or low blood pressure Rapid pulse Short temper Puffy face The Structural-Muscular/Skeletal System Check: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply. Skeletal 1 2 3 Pain, swelling, stiffness in joints Joint inflammation (rheumatoid arthritis) Pain, stiffness, inflammation of spine Facial pain Joints make popping sounds Gout Ankylosing spondylitis Bones fracture easily Gradual loss of height Tooth loss; teeth “falling out” Lack of exercise Rounding of shoulders; stooping F: Menopause Pain in forearm or biceps Cramps in calf muscle during sleep or exercise Painful cramping of feet or toes Teeth prone to decay, frequent toothaches Malformation of bones Insomnia Muscles weak, weak grip, light objects feel heavy Heart palpitations Diet high in animal foods (meat, dairy, eggs) Muscular 1 2 3 Muscle pain Muscle weakness Sprains; muscle strains Muscle(s) spasm Neuromuscular 1 2 3 Muscles wasting in some part of the body Numbness or loss of sensation Mood swings and/or depression Blurred or double vision Tingling and/or numbness, especially in extremities Muscular stiffness Difficulty breathing M: impotence Tremors Loss of peripheral vision Slurred speech Objects fall from hands, reach in wrong place Hands tremble Impaired speech Thank you for completing this NSP Form. Please leave any comments below and expect to receive a follow through within a few days. – Amanda Froelich Comments: Submit Should be Empty: Submit a Comment Cancel replyYour email address will not be published. Required fields are marked *Comment * Name * Email * Website Δ
