Nutritional Deficiency Questionnaire

Nutritional Deficiency Questionnaire

1. Do you often feel fatigued or have low energy levels even after sufficient rest? (Possible deficiencies: B vitamins, iron, vitamin D)
2. Do you experience frequent muscle cramps or weakness? (Possible deficiencies: magnesium, potassium, calcium)
3. Have you noticed any issues with your skin, such as dryness, rashes, or dermatitis? (Possible deficiencies: vitamin A, vitamin E, zinc, essential fatty acids)
4. Do you often feel depressed, anxious, or have difficulty concentrating? (Possible deficiencies: B vitamins, vitamin D, omega-3 fatty acids)
5. Are you experiencing hair thinning or hair loss? (Possible deficiencies: iron, zinc, biotin, vitamin D)
6. Do you have bleeding gums or slow wound healing? (Possible deficiencies: vitamin C, zinc, vitamin K)
7. Are you experiencing numbness, tingling, or burning sensations in your hands or feet? (Possible deficiencies: vitamin B12, magnesium)
8. Do you have difficulty swallowing or experience sore tongues? (Possible deficiencies: vitamin B12, iron, folate, niacin)
9. Have you noticed increased susceptibility to infections or frequent colds? (Possible deficiencies: vitamin A, vitamin C, zinc, vitamin D)
10. Do you experience bleeding or easy bruising? (Possible deficiencies: vitamin K, vitamin C, zinc)
11. Are you often constipated or have irregular bowel movements? (Possible deficiencies: magnesium, fiber, vitamin B9)
12. Do you get short of breath during exertion? (Possible deficiencies: iron, vitamin B12, folate)
13. Have you experienced poor night vision or difficulty seeing in low light? (Possible deficiencies: vitamin A, zinc)
14. Do you feel anxious about your overall health or have doubts about getting enough nutrients? (Possible deficiencies: B vitamins, magnesium, vitamin D)
15. Do you follow a restrictive diet, such as vegetarian or vegan, that might impact certain nutrient intake? (Possible deficiencies: vitamin B12, iron, zinc, omega-3 fatty acids)
16. Have you had any recent weight loss or drastic changes in your eating habits? (Possible deficiencies: iron, vitamin B12, folate, calories overall)
17. Do you consume enough dairy, green leafy vegetables, nuts, or fortified foods? (These contribute to: calcium, magnesium, vitamin D, vitamin K, zinc)
18. Are you pregnant, breastfeeding, or planning pregnancy? (Nutritional considerations: folate, iron, iodine, vitamin D)
19. Do you drink alcohol frequently or have a history of heavy alcohol use? (Possible deficiencies: thiamine, folate, zinc, vitamin B1)
20. Have you undergone surgery or medical conditions that impair the digestion or absorption of nutrients?(Possible deficiencies: multiple, depending on the condition, including vitamin B12, iron, fat-soluble vitamins, zinc)

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