NUTRITION ASSESSMENT
This Nutrition Assessment Form has been compiled in order to assist you in determining what supplements could best assist you. Please feel free to print it out and check off the symptoms that apply to you. The results at the bottom of the page tell you what vitamins you may lacking in your body. This is only a guide by which some people have been able to determine the various supplements, which may help their particular conditions.
If you have persistent problems or symptoms, you should always seek the advice of a nutritionally minded physician.
B-COMPLEX
_____ Frequent fatigue
_____ Irritability
_____ Depression
_____ Craving for sweets, alcohol, or coffee
_____ Fits of temper
_____ Hurt all over
_____ Heart palpitations
_____ Hair loss
_____ Digestive problems, gas, burping, etc.
_____ High stress level
_____ Mood changes & anxiety attacks
_____ Cracks at the corners of the mouth
_____ Carpal Tunnel Syndrome
_____ Excessive fluid retention
_____ PMS
_____ Headaches
_____ Graying hair
_____ Memory problems
_____ Arteriosclerosis
_____ Woman of child bearing age
_____ Interested in preventing cancer
HYPOGLYCEMIC TENDENCIES
_____ Emotional on empty stomach
_____ Shakiness, headaches, relieved by sweets
_____ Weak spells, tiredness, mid-afternoon
_____ Faintness, dizziness, lack of concentration
_____ Irritable before breakfast or if meal is missed
_____ Intense, frequent thirst
INSTANT PROTEIN
_____ Frequent fatigue
_____ Mood swings
_____ Irritability
_____ Weakness in general
_____ High levels of stress
_____ Excessive fluid retention
_____ Poor muscle tone
_____ Splitting nails
_____ Dry, lifeless hair
_____ Loss of concentration
_____ Hair loss
_____ Slow wound healing
_____ recurrent colds, flus or infections
_____ premature aging
_____ Hypoglycemic tendencies
_____ Low resistance to infection
_____ Exercise often
_____ Vegetarian
ZINC
_____ Poor sense of smell or taste
_____ White spots on fingernails
_____ Dandruff
_____ Acne, especially teenage acne
_____ Perspire heavily or often
_____ Chronic colds and flus
_____ Slow healing of wounds
_____ White-coated tongue
_____ Taking estrogen
_____ Thinning hair
_____ Prostate problems
_____ Fertility problems
_____ Diabetes
_____ Anorexia
_____ High levels of stress
IRON PLUS VITAMIN C
_____ Poor circulation
_____ Dark circles under the eyes
_____ Heavy menstrual flow
_____ Pale skin, palms very pale
_____ Lack of stamina
_____ History of anemia
_____ Thin, fragile, brittle nails
VITAMIN E PLUS SELENIUM
_____ Heart conditions
_____ Shortness of breath on exertion
_____ Hot flashes
_____ Diminished sex drive
_____ Breast tenderness
_____ Cystic conditions/fibrocystic disorders
_____ Cold hands and feet
_____ Psoriasis
_____ Leg pain
_____ Low exercise tolerance
_____ Hormonal imbalances
_____ High blood pressure
_____ History of tumors
_____ Scar formation
_____ Blood clots
_____ Excessive exposure to sunlight, x-rays or radiation
_____ History of miscarriages
_____ Sterility
_____ Eat fried and processed foods
_____ Poor circulation
_____ Premature Aging
_____ Aging spots on skin
_____ Interested in preventing cancer
_____ HIV virus
CALCIUM MAGNESIUM
_____ Muscle cramps (as well as leg, foot)
_____ Insomnia
_____ Frequent backache
_____ Headaches
_____ Arthritis
_____ Muscle tension
_____ Irregular heartbeat
_____ Joint pains
_____ Osteoporosis
_____ PMS, menopause
_____ Consume less than 3 servings per day of milk, yogurt or cheese
_____ Joints pop or crack
_____ Menstrual cramps
_____ Muscle twitching or “tics”
_____ Crave chocolate
_____ Insomnia
BETA CAROTENE
_____ Acne, blackheads, warts
_____ Dry, rough skin
_____ Difficulty seeing at night
_____ Permanent “goosebumps” on backs of arms
_____ Frequent colds
_____ History of Bronchitis, asthma or pneumonia
_____ Conjunctivitis, dry eyes
_____ Smoke cigarettes
_____ History of cancer
_____ Cataracts or Glaucoma
_____ Premature aging
_____ Aging spots on skin
_____ Interested in preventing cancer
_____ Eat less than 3-5 servings of fresh veggies a day
VITAMIN C
_____ Bleeding gums
_____ Smoke cigarettes
_____ Varicose veins
_____ Frequent colds and flu
_____ Bruise easily
_____ Hangnails, cuticles tear easily
_____ Nosebleeds
_____ Slow healing of wounds/fractures
_____ Allergies
_____ Arthritis
_____ History of cancer
_____ High cholesterol
_____ Heart disease
_____ High level of stress
_____ Interested in preventing cancer
_____ Eat less than 2-4 svgs fresh fruit, 3-5 svgs. veggies a day
FORMULA I
_____ Repeated colds, infections or flus
_____ Swollen glands
History of:
_____ Cancer
_____ Multiple Sclerosis
_____ Herpes
_____ Chronic Fatigue or Epstein Barr
_____ Rheumatoid Arthritis
_____ Parkinson’s disease
_____ Lupus
_____ Want to strengthen the immune system
_____ Interested in preventing cancer
ALFALFA
_____ Allergies
_____ Asthma
_____ Joint Pains
_____ Arthritis
_____ Carpal Tunnel Syndrome
_____ Digestive problems; gas, bloating, burp, etc.
_____ Excessive fluid retention
_____ Kidney or bladder infections
_____ Sinus problems
_____ Ulcers
_____ Colon problems
_____ Body odor
_____ Bad breath
_____ Puffy eyes
_____ Swollen ankles and feet
_____ Difficult or painful urination
_____ Sleep disturbed by urge to urinate two or more times per night
_____ Smelly feet
_____ Hiatel Hernia
_____ Diabetes
_____ Constipation
_____ Abdominal pain after large meal
OSTEOKINETICS
_____ Osteoarthritis
_____ Joint pain and/or tenderness
_____ Swollen joints
_____ Cartilage degeneration
_____ Decreased mobility
_____ Repetitive movements during work
_____ Repetitive sports activities
_____ Want to support optimal joint function
_____ overweight and/or sedentary lifestyle
LECITHIN AND EPA (Essen. fatty acids)
_____ Trying to lose weight
_____ Cold hands or feet
_____ Poor memory or memory worsening
_____ Arms or legs often go to sleep
_____ Bruise easily—black & blue spots
_____ Tingling in lips and fingers
_____ Poor circulation
_____ Learning disabilities
_____ Problems eating fatty foods
_____ High cholesterol
_____ Eat fried & processed foods
_____ Eczema, psoriasis, skin eruptions
_____ Growth retardation
_____ Uncoordinated movement
_____ Sterility in males
_____ Miscarriage in females
_____ Diminished sex drive
_____ High blood pressure
_____ Migraine headaches
_____ High levels of triglycerides
_____ Blood clots and aneurysms
_____ Liver problems and toxicity
_____ Arthritis, lupus, auto-immune disorders
_____ Multiple Sclerosis
_____ Pregnant or nursing woman
_____ History of stroke
_____ Menstrual irregularities or PMS
_____ Menopause
_____ Carpal Tunnel Syndrome
GARLIC
_____ Throat and ear infections
_____ Frequent diarrhea, dysentery
_____ Fungal infections
_____ High cholesterol & triglycerides
_____ Blood clots
_____ Indigestion
_____ Allergies
_____ Sinus infections
_____ Ulcers
_____ Colitis
_____ Repeated viral or bacterial infections
_____ Infected wounds
_____ History of bronchitis
_____ Frequent sore throats
_____ History of cancer
_____ Heavy metal toxicity (i.e. lead or mercury)
_____ Candida infections
_____ Excessive fluid retention
_____ Premature aging
_____ Interested in preventing cancer
_____ Tumors
ASIAN GINSENG COMPLEX*
_____ Depression
_____ Physical and mental fatigue
_____ Poor resistance to disease
_____ Poor physical performance
_____ Low endurance
_____ Low blood pressure
_____ Diminished sex drive
_____ Digestive disturbances
_____ Poor appetite
_____ Poor circulation
_____ High cholesterol
_____ High blood sugar, diabetes
ECHINACEA COMPLEX*
_____ Lowered resistance
_____ Viral infections
_____ Bacterial infections
_____ Upper respiratory infections
_____ Blood poisoning
_____ Abscesses
_____ Swollen glands
_____ Pus or boils
_____ Bladder infections
_____ Mastisis
_____ Venereal diseases
*can also be used for snake or spider bites or gangrene
VALERIAN PLUS*
_____ Insomnia
_____ Muscle tension
_____ Stress
_____ Over-excitability
_____ Hsyteria
_____ Stomach cramps
_____ Intestinal colic
_____ Gas pains
_____ Migraine headaches
_____ Rheumatic pain
PEPPERMINT-GINGER PLUS*
_____ Upset stomach
_____ Intestinal colic
____ Morning sickness
_____ Acid indigestion
_____ Colitis
_____ Anxiety
_____ Fevers
_____ Colds & flus
_____ Travel sickness
_____ Painful periods
HERBLAX & FIBER
_____ Constipation
_____ Frequent headaches or migraines
_____ History of hemorrhoids
_____ History of colon problems
_____ Acne
_____ Work around toxic chemicals
_____ Consume processed foods
_____ Body odor
_____ Diabetes
_____ Thin, pencil-like bowel movements
_____ Rarely have daily bowel movements
_____ Eat less than 6-11 servings of whole grains per day
_____ Eat less than 3-5 servings of fresh vegetables per day
____ Eat less than 2-4 servings of fresh fruit per day
CLARITY
_____ Short term memory loss
_____ Difficulty concentrating
_____ ADD
_____ Senile dementia
_____ Alzheimer’s
_____ Head injury
_____ Gout
_____ Varicose veins
_____ Heart disease
_____ Impotence
_____ Poor eyesight
_____ Depression
_____ Diabetic retinopathy
_____ Asthma
_____ Swelling of hands and feet
_____ Poor circulation to extremities
_____ Glaucoma, cataracts
_____ High blood pressure
DTX
_____ Live, work or commute in polluted area
_____ Exposure to toxic substances (ammonia,insecticides, paints, fertilizers)
_____ Eat a lot of processed foods
_____ Exposed to smoke from grilling foods
_____ Alcohol & drug use
_____ Use of medications (steroids, chemotherapy,
oral contraceptives, high dose of aspirin, ibuprofen or acetaminophen)
_____ History of hepatitis or Cirrhosis of the liver
_____ Candida overgrowth
_____ Gallstones
SYMPTOMS OF A TOXIC LIVER
PMS
Fibrocystic breasts
Food allergies
Acne
Elevated cholesterol
Fatigue, sluggishness
Mental confusion, poor memory, depression, anxiety
Nausea, diarrhea, constipation
Light or gray-colored stools
Slow wound healing
Itching or peeling skin
Sore or burning feet
Hair loss
Bitter taste in mouth
Low blood sugar
Frequent or urgent urination
Sinus problems
Excessive mucous formation
Bags or dark circles under the eyes
IMPORTANT NOTE:
The symptoms, conditions and tendencies listed above are conditions for which some people have found relief by using the corresponding food supplements. In no way should this form be mistaken as a diagnosis of a disease nor should the use of supplements be expected to “cure” any disease.
*indicates best used occasionally as needed
B-complex ______ out of 21
Hypo-gl. ______ out of 6
Protein _____ out of 18
Calcium-Mag _____ out of 17
Beta Carotene _____ out of 15
Vitamin C _____ out of 17
Vitamin E _____ out of 24
Formula I _____ out of 11
Zinc _____ out of 15
Alfalfa _____ out of 22
Osteokinetics _____ out of 9
Lecithin/EPA _____ out of 30
Iron _____ out of 7
Garlic _____ out of 23
Asian Ginseng _____ out of 12
Echinacea _____ out of 11
Valerian _____ out of 10
Peppermint-Ginger ______ out of 10
Herb-Lax/Fiber _____ out of 14
Clarity _____ out of 18
DTX _____ out of 9
TOTAL SCORE:
B-complex ______ out of 21
Hypo-gl. ______ out of 6
Protein _____ out of 18
Calcium-Mag _____ out of 17
Beta Carotene _____ out of 15
Vitamin C _____ out of 17
Vitamin E _____ out of 24
Formula I _____ out of 11
Zinc _____ out of 15
Alfalfa _____ out of 22
Osteokinetics _____ out of 9
Lecithin/EPA _____ out of 30
Iron _____ out of 7
Garlic _____ out of 23
Asian Ginseng _____ out of 12
Echinacea _____ out of 11
Valerian _____ out of 10
Peppermint-Ginger ______ out of 10
Herb-Lax/Fiber _____ out of 14
Clarity _____ out of 18
DTX _____ out of 9
I hope this has been of help to you *S* Before I started Shaklee I never realized that a lot of our health problems are due to a vitamin deficiency. Our bodies loose nutrients through stress and sickness and we need supplements to fight off disease and to build a strong immune system. If you have any questions on any of this, please feel free to email me. This has changed my life and so many ways and my goal is to share it with as many people as I can. Take care!!
