NSP Form Evaluation

  • NSP Form

    Thank you for filling out the NSP form which accompanies the Lifestyle Assessment for Holistic Nutrition consultation.

  • 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.

  •   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.

  •   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.

  •   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
  •   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
  •   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
  •   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
  •   1 2 3
    Severe abdominal pain
    Nausea and vomiting
    Slow digestion; feel full for hours after eating
    Fever
    Alcohol addiction
    Jaundice
  •   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.

  •   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
  •   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.

  •   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
  •   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.

  •   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
  •   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
  •   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
  •   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.

  •   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)
  •   1 2 3
    Muscle pain
    Muscle weakness
    Sprains; muscle strains
    Muscle(s) spasm
  •   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

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