Health questionnaire

Part One: Lifestyle Factors and Clinical Indicators of Vitamin and Mineral Deficiency
Indicate yes or no for each question.
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1On average, do you eat fewer than five fruit and Insufficient intake of fruits and vegetables (less than five servings per day) deprives the body of many necessary nutrients including antioxidants, B vitamins, and phytonutrients. 2Do you often experience a scaly, flaky, Flaky seborrheic conditions on the face are associated seborrheic condition at the outer nose margins with deficiencies in vitamins B2 and B6. 3Do you have soft nails or nails that chip, crack, or Soft nails or nails that chip, crack or peel easily, and/or peel easily, and/or are brittle or contain ridges are brittle or contain ridges (not smooth), often are caused by deficiencies in calcium and other minerals. 4Are there white spots under your fingernails? White spots under your fingernails often are a sign of 5Have you noticed small red spots under your Red spots under the skin often are an indicator of 6On average, do you consume more than three Consuming more than three alcoholic beverages per week, on average, is associated with depletion of the following nutrients: vitamin A beta-carotene and other carotenoids vitamin B1 vitamin B2 vitamin B3 vitamin B6 vitamin B12 pantothenic acid vitamin C vitamin D vitamin E potassium Alcohol consumption also produces increased exposure to free radicals. 7On average, do you drink more than two cups of Drinking more than two cups of coffee or caffeinated tea coffee or caffeinated tea (of any kind) per day? (or any kind) per day, on average, deplete the body of vitamin C, many B vitamins, and minerals.
Smoking cigarettes increases free-radical exposure and depletes the body of antioxidants, B vitamins, and 9Has your skin been damaged by sunlight and/or Damage to the skin from sunlight and tanning beds do you use a tanning bed more than once per results in the production of free radicals and depletion of antioxidants that protect the skin from future ultraviolet light exposure. 10On a scale of one to five, is the daily stress level It appears your stress is at a level sufficient to create in your life three or greater, if one is a low level or hormonal imbalances that can lead to the depletion of stress and five e is a high level of stress? vitamin C, many B vitamins, and minerals. 11Do you often experience cracks at the margins of Cracks at the margins of the lips often are associated 12Do you often experience a sore or burning A sore or burning tongue often is caused by deficiencies in vitamins B2, B6, and B12. DR. LO UIE YU FO RM ULAT IONS: HEALT H QUEST IONNAIRE Part One: Lifestyle Factors and Clinical Indicators of Vitamin and Mineral Deficiency
Indicate yes or no for each question.
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13 Have you experienced a reduced ability to taste A reduced ability to taste food often is caused by a zinc Gums that bleed easily often signal vitamin C Skin that bruises easily often is associated with a deficiency in vitamin C, calcium, and/or vitamin K? 16 Are you a slow healer from bruises and cuts? Slow healing capabilities often indicate suboptimal Feeling chronically fatigued in the absence of disease often is associated with multiple vitamin and mineral 18 Do you have irregular eating patterns? Irregular eating patterns tend to contribute to inadequate intake of essential vitamins and minerals, which often leads to at least marginal deficiencies. 19 Are you on a weight-loss or calorie-restricted Calorie-restricted diets cannot provide optimal intake levels of all vitamin and minerals, thereby continuing to marginal deficiency states. Individuals on calorie- restricted diets (less than 2000-2500 calories per day) are advised to derive the missing nutrients from a multiple vitamin/mineral. Feeling run down and/or in a weakened state of experiencing a weakened state of immunity? immunity suggests multiple nutrient deficiencies might be a factor. Studies reveal that supplementation with certain antioxidant vitamins, as well as zinc and selenium, can bolster immune function in older subjectsand in those with certain types of compromised immunefunction. 21 Does your hair fall out easily, and/or is it dry and Hair that falls out easily, dry and brittle hair, and/or brittle, and/or does it lack optimal lustre and lacklustre hair that is dull in appearance are all associated with multiple vitamin and mineral deficiencies. D R . L O U I E Y U F O R M U L A T I O N S : H E A L T H Q U E S T I O N N A I R E Part Two: Drugs Causing Nutrient Depletion
Do you regularly use any of the following medications or agents? Indicate yes or no for each question.
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F e e d b a c k for Yes Answers
Your regular use of laxatives is associated with depletion of the following nutrients: vitamin A Your regular use of antibiotics is associated with depletion of the following nutrients: vitamin B1 vitamin B2 biotin pantothenic acid 3Cholesterol-lowering drugs: cholestyramine, Your regular use of cholesterol-lowering drugs is Colestipol, Questran, Colestid, Atromid-S associated with depletion of the following nutrients: vitamin A vitamin D Your regular use of colchicine to treat gout is associated with depletion of the following nutrients: vitamin A vitamin D 5Steroid hormones: cortisone, prednisone, etc. Your regular use of certain steroid drugs is associated with depletion of the following nutrients: folic acid 6Aspirins for arthritis or any other reason (or other Yes Your regular use of nonsteroidal anti-inflammatory nonsteroidal anti-inflammatory drugs: ibuprofen, drugs is associated with depletion of the following DR. LO UIE YU FO RM ULAT IONS: HEALT H QUEST IONNAIRE Part Two: Drugs Causing Nutrient Depletion
Do you regularly use any of the following medications or agents? Indicate yes or no for each question.
Q u e s t i o n
Responses
F e e d b a c k f o r Y e s A n s w e r s
7 Antacids: Maalox, Turns, Mylanta, Rolaids, Your regular use of antacid drugs is associated with Your regular use of oral contraceptive drugs is associated with depletion with depletion of the followingnutrients: Your regular use of sedative and/or barbiturate drugs is associated with depletion of the following nutrients: Your regular use of estrogen replacement therapy is associated with depletion of the following nutrients: vitamin B1 11 Caffeine: caffeinated coffee, tea, espresso, etc. Your regular intake of caffeine is associated with depletion of the following nutrients: vitamin B1 D R . L O U I E Y U F O R M U L A T I O N S : H E A L T H Q U E S T I O N N A I R E Part Two: Drugs Causing Nutrient Depletion
Do you regularly use any of the following medications or agents? Indicate yes or no for each question.
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Response Feedback
Your regular habit of smoking is associated with depletion of the following nutrients: 13Antidepressants: Prozac, Paxil, Zoloft, Celexa, Your regular use of antidepressant drugs is associated with depletion of the following nutrients: 14Amphetamines: Adderall, Cylert, Ritalin, Your regular use of amphetamines is associated with Your regular use of Levodopa is associated with 16Anticonvulsants: Dilantin, Celontin, Zorontin, Your regular use of anticonvulsant drugs is associated with depletion of the following nutrients: 17Heart medications: digoxin or Digitalis Your regular use of digoxin is associated with depletion 18Inflammation/pain medications: indomethacin Your regular use of indomethacin is associated with depletion of the following nutrients: 19Diuretics: thiazide drugs, hydrocholorothiazide, Your regular use of diuretic drugs is associated with depletion of the following nutrients: vitamin B1 calcium 20High blood pressure, ACE-inhibitor drugs: Your regular use of ACE-inhibitor drugs for high blood Captopril, Capoten, Lotensin, Vasotec, Ramipril, pressure is associated with depletion of the following 21High blood pressure, beta-blockers: atenolol, Your regular use of beta-blocker high blood pressure drugs is associated with depletion of the following 22High cholesterol, statin drugs: Lipitor, Crestor, Your regular use of statin drugs for high cholesterol is associated with depletion of the following nutrients:

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