Nutritional
Questionnaire
Simply put a check mark beside any symptom that applies to you
Section 1 (Gastrointestinal)
Part A (Stomach, Pancreas, Small Intestine)
___Indigestion/gas after eating
___Feel too full after eating, bloating
___Sleepy or low energy after eating
___Uncomfortable or adverse reactions after eating
___Diet consists of mostly processed and cooked food
___The need to eliminate soon after eating
___Diarrhea after eating
___Difficulty breathing after eating
___Food passes through undigested
___Three or more large bowel movements daily
Total ____
Part B (Colon)
___Hard, small stool
___Mucus in stool
___Constipation or straining during bowel movement
___Rectal pain, itching, burning
___Thin, pencil-like bowel movements
___No urge to move bowels
___Almost continued urge to have bowel movement
___Hemorrhoids or rectal fissure
___Diarrhea/loose stool
___Camping in lower abdomen
Total ____
Part C (Microbe, Yeast, Para)
___Repeated use of antibiotics, steroids or birth control pills
___Cravings for sugars, bread, alcohol
___Severe reactions to perfume, tobacco or chemical odors
___Hyper-sensitivity to certain foods (gluten?)
___Teeth grinding
___Recurrent Bladder infections
___Coated or sore tongue
___Feel bad all over without apparent cause
___Hives, psoriasis or skin rash
___Tiredness, feelings of being drained
Total ____
Section 2 (Liver and Gallbladder)
___Fats/greasy foods cause nausea, headaches
___High cholesterol
___Stool appears yellow, clay-colored, foul odor
___Skin oily on nose and forehead
___Constipation
___Bad breath/bad taste in mouth, excess body odor
___Pain/tenderness behind the right lower rib area
___Brown spots on the skin
___History of gallstones
___General poor health
Total ____
Section 3 (Endocrine)
Part A (Thyroid)
___Heart seems to miss beats or turn “flip flops”
___Cold hands or feet/Sensitivity to cold, prefer warm climate
___Hair scanty, dry, brittle, dull, lusterless, lifeless
___Flaky, dry, rough, skin
___High cholesterol
___Constipation, less than one bowel movement a day
___“Go to pieces” easily, cry easily
___Diminished sex drive
___Gain weight easily, fail to lose on diets
___Depression
Total ____
Part B (Adrenal)
___Eyes sensitive to bright lights, headlights, sunlight
___Fatigue, especially between 2-6pm
___Dizzy when rising or standing up from a kneeling position
___Form “gooseflesh” easily or “cold sweats”
___Prefer being alone, uneasy when center of attention
___Blood pressure fluctuates, sometimes too low
___Allergies, such as skin rash, dermatitis, hay fever, asthma, etc
___Emotional upsets cause complete exhaustion, must go and lie down when
under heavy stress
___Unusual craving for salt
___more than usual neck, head, shoulder tension
Total ____
Section 4 (Glucose)
Part A (Glucose High)
___Frequent urination
___Unusual thirst
___Unusual hunger
___Vision blurs
___Sense of drowsiness, lethargy during the day not associated with missing
meals or not sleeping
___Loss of hair on your legs
___Slow healing of wounds, cuts, abrasions
___Breath smells sweet or of acetone
___Peculiar sensations in hands or feet --- tingling, burning, sharp jabs,
numbness, etc
___Urine contains sugar
Total ____
Part B (Glucose Low)
___Nervousness, shaky feelings or headaches relieved by eating sweets
___Irritable if late for a meal or miss a meal
___Irritable before breakfast
___Sudden strong craving for sweets, coffee or alcohol
___Get hungry soon after eating
___Wake up at night feeling hungry
___Wake up in the middle of the night and can’t go back to sleep
___Mind goes blank at times
___Feel best after a good meal
___Agitation, easily upset, nervous
Total ____
Section 5 (Cardio)
___High blood pressure
___Pain, pressure, tightness or heaviness around the chest
___Exhaustion with minor exertion
___Difficulty catching breath, especially during exercise
___Heart pounding, sensation of heart beating too quickly, too slowly or
irregularly
___Swelling in feet, ankles and/or legs comes and goes for no apparent reason
___Fingers and/or toes go cold
___Arms and/or legs “go to sleep”
___Numbness or heaviness in arms or legs
___Sharp, diagonal crease in earlobe
Total ____
Section 6 (Mood)
___Family, friends, work, hobbies or activities you hold dear are no longer of
interest
___Cry frequently
___Feeling miserable, sad, unhappy or blue
___Sleep problems – too much or too little sleep
___Does every little thing get on your nerves and wear you out
___Do you feel easily agitated
___Often feel “Butterflies in your stomach,”
___Are you easily upset or irritated
___Go to pieces if you don’t control yourself
___Little annoyances get on your nerves and make you angry
Total ____
Section 7 (Immune)
___Allergies
___Frequent colds or flu-like symptoms
___Frequent sore throats
___Swollen lymph nodes
___Mucus in eyes when waking up in morning
___Tonsils removed
___Cough up lots of phlegm
___Plugged ears/discharge from ears
___Sinus congestion/problems
___Lung congestion/issues
Total ____
Section 8 (Urinary)
___Cramping or pain on either side of lower back
___Restricted urine flow
___Puffiness around eyes
___Frequent urinary tract infections
___Burning upon urination
___High diastolic blood pressure (above 90)
___Rarely feel the urge to urinate
___Strong smelling urine
___Urine is a rose color
___Generalized sense of water retention throughout your body
Total ____
Section 9 (Musculoskeletal)
___Bones ache, feel tender or sore
___Upper or lower back pain
___Pain when sitting down or walking
___Teeth are prone to decay
___Joint swelling, pain or stiffness involving one or more areas (fingers, hands,
wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)
___A routine exercise program, like daily walking, causes your knees to swell or
hurt
___Injure, strain or sprain easily
___Muscles stiff, sore, tense and/or achy
___Muscle cramps or spasms/twitches
___Specific points on the body feel sore when pressed
Total ____
Section 10 (CNS Brain)
___Tremors in hands and feet
___Eyesight, sense of smell and taste or ability to hear not as sharp as it used to
be
___Irritability or impatience
___Loss of stamina while doing physical work
___Speaking and forming words does not feel automatic
___Difficulty absorbing new information
___Tend to forget things
___Trouble thinking or concentrating
___Easily distracted
___Inability to sit still for any length of time, even at mealtime
Total ____
Section 11-MALE ONLY (Prostate)
___Difficulty urinating – starting, burning
___Above associated with back or leg pains
___Have to urinate more than twice during night
___Sensation of not emptying your bladder completely
___Find yourself needing to start and stop again several times while urinating
___Find it difficult to postpone urinating
___Need to push or strain to begin urinating
___Lost or diminished sex drive
___Impotence
___Premature ejaculation
Total ____
Section 12 - FEMALE ONLY (Hormones)
Part A (PMS)
Indicate which conditions apply only if they occur within 14 days prior to and two
days after menstrual period: (Menopausal women skip to Part B)
___Anxiety, nervous tension
___Irritability, restlessness
___Depression
___Mood swings, emotional outbursts, crying spells
___Headache
___Backache, cramps
___Bloating, weight gain
___Craving for sweets
___Breast tenderness
___Swelling of hands, feet, edema
Total ____
Part B (Hormones)
___Vaginal discharge
___Vaginal dryness
___Sexual intercourse is uncomfortable
___Interest in having sex is low
___Difficulty with orgasm
___Sense of well-being fluctuates throughout the day for no apparent reason
___Sudden hot flashes
___Chills
___Mental fogginess, forgetful or distracted
___Difficulty sleeping
Total ____
Section 13 (Specific Nutrients)
Part A (Essential Fatty Acids)
___Dry, flaky skin
___Dryness or cracks behind the ears
___Brittle hair and/or fingernails
___Acne
___Dry or oily hair
___Eczema/psoriasis/dermatitis
___Alopecia (patchy hair loss)
___Dry patches of scaly skin on the face and/or nose
___Patches of hair which are unmanageable (stick up on end)
___Split ends
Total ____
Part B (Protein, Aminos)
___Excess fluid retention (edema) in hands or feet
___Nausea or dizziness
___Poor coordination
___General, overall weakness
___Anemia
___Cataracts
___Catch colds, flu, infections easily
___Muscle wasting
___Premature aging
___Hair dull, dry, sparse, loose and falling out
Total ____
Part C (CoQ10)
___Muscular weakness
___Heart rhythm disturbances
___Enlarged heart
___Chronic unrelenting fatigue
___Bleeding gums
___Receding gums
___High blood pressure
___History of angina and/or coronary artery disease
___History of congestive heart failure
___Experience severe muscle pain, particularly after exercising
Total ____
Part D (Vitamin C)
___Skin bruises easily, “black & blue” marks
___Gums bleed easily, especially when brushing teeth
___Loose teeth, loss of dental fillings
___Cuts, sores or wounds heal slowly
___“Fleeting” pains in joints or legs, joint tenderness
___Catch infections, colds, flu or viruses easily
___Nosebleeds
___Broken capillaries, hemorrhages or little pink spots on skin
___Anemia
___Fragile bones
Total ____
Part E (Vitamin D)
___Poor bone development
___Abnormal number of dental cavities
___Osteoporosis (demineralized bones)
___Osteomalacia (softening of bones)
___Rickets (bowlegs, knock-knees)
___Joint pains
___Muscular cramps
___Nearsightedness, myopia
___Nervousness
___Insomnia
Total ____
Part F (Iodine)
___Dry hair
___Brittle nails
___Slow mental reactions
___High cholesterol in blood
___Enlargement of thyroid gland, goiter
___Heart palpitations
___Irritability
___Overweight, obese
___Sluggish metabolism
___Constipation
Total ____
Please list any problems, symptoms or conditions that have not been covered in
this questionnaire:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Low
Moderate
High
NAME: _________________________________
9.
Mus
culo
10.
CNS
Brain
11.
Male
10
8.
Uro
10
7.
Im
mu
10
6.
Mood
10
5.
Car
-dio
10
4.
Glucose
10
3.
Endocrine
10
2.
LV/
GB
10
Prostate
1.
Gastrointestinal
10
10
10
10
10
10
10
8
7
6
5
4
3
2
1
CNS/Cognition
9
8
7
6
5
4
3
2
1
Musculoskeletal
9
Kidney/Bladder
9
8
7
6
5
4
3
2
1
Lymph, Sinus, Lungs
9
8
7
6
5
4
3
2
1
Depression/Anxiety
9
8
7
6
5
4
3
2
1
Heart & Circulation
9
8
7
6
5
4
3
2
1
B. Glucose – low
9
8
7
6
5
4
3
2
1
A. Glucose – high
9
8
7
6
5
4
3
2
1
B. Adrenal
9
8
7
6
5
4
3
2
1
A. Thyroid
9
8
7
6
5
4
3
2
1
Liver/Gallbladder
9
8
7
6
5
4
3
2
1
C. Microbe/Yeast/Para
9
8
7
6
5
4
3
2
1
B. Colon
9
8
7
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
A. Stomach/Pancreas/
Small Intestine
10
10
10
10
Nutritional Questionnaire Key
Section 1 GI Tract
A. Stomach/Pancreas/Small Intestine
Primary Support
a.
BetaZyme 1-2 per meal (do not use if ulcer is present,
introduce after ulcer is healed) use ProbZyme if
BetaZyme is contraindicated
b.
GI Complete 1-2 servings per day
c.
Super Biotics 1-2 capsules daily on empty stomach
Additional Considerations
a.
Frontier Biotics 2 capsules twice daily on empty
stomach
B. Colon
Primary Support
a.
Frontier Cleanse 4 capsules twice daily (be sure of
adequate fluid intake)
b.
Super Biotics 1-2 capsules daily on empty stomach
c.
GI Complete 1-2 servings daily
Secondary Support
a.
Frontier Fiber 1-2 servings daily
b.
GI Tincture 1-2 droppers 3-6 times daily
C. Microbial Imbalance
Primary Support
a.
ParaCleanse 3 tablets twice daily on empty stomach
b.
CandiKill - 2 per meal
c.
SBC Extra Strength 2-4 capsules daily
d.
Micro-Gone Tincture 1-2 droppers 3-6 times daily
Secondary Support
a.
Olive Leaf Extract - 1 cap each meal
b.
Immune Tincture 1-2 droppers 3-6 times daily
c.
Frontier Cleanse 4 capsules twice daily
DATE: ___________________
10
13
10
Specific Nutrients
10
F. Iodine
12.
Female
10
E. Vitamin D
9
8
7
6
5
4
3
2
1
D. Vitamin C
9
8
7
6
5
4
3
2
1
C. CoQ10
9
8
7
6
5
4
3
2
1
B. Protein/Aminos
9
8
7
6
5
4
3
2
1
A. Essential Fatty Acids
9
8
7
6
5
4
3
2
1
B. Hormones
9
8
7
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
9
8
7
6
5
4
3
2
1
A. PMS
Section 2
Liver/Gallbladder
Consider detox
program for 10-30
days
Primary Support
a.
BetaZyme 1-3 per meal to assist in the digestion of
lipids/fats
b.
LivClear II as directed to support detoxification
pathways and bile production
c.
Liver/Gallbladder 1-2 droppers 3-6 times daily
Secondary Support
a.
ProLean Greens 1-2 servings daily (can be mixed
with Power Cleanse) to support the body’s ability to
cleanse, detoxify and rejuvenate
b.
Green Tea 70 1 capsules twice daily to increase
activity of detoxifying enzymes within the liver
c.
EnerDMG 2-3 tablets daily to assist detoxification
Section 2
Liver/Gallbladder
(continued)
Section 3 Endocrine
Additional Considerations
a.
Frontier Cleanse 4-8 capsules daily to assist
detoxification through the bowels
b.
Power Q 1-2 tablets daily for liver support and to aid
detoxification processes
c.
CholestoCare II if cholesterol is a concern
A. Thyroid
Primary Support
a.
Iodine Plus 1-3 capsules daily for comprehensive
thyroid support (or consider liquid form)
b.
AdrenaMax II 1 capsule each meal to reduce levels of
stress hormones
Secondary Support
a.
Endocrine Tincture 1-2 droppers 3-6 times daily
b.
Frontier Flax 1 softgel per meal for overall health of
the endocrine system
c.
Adrenal Tincture 1-2 droppers 3-6 times daily
B. Adrenal
Primary Support
a.
AdrenaMax II 1 capsule each meal
b.
Pro Oranges 1 serving morning, 1 serving early
afternoon to help better manage stress hormones
c.
Super B Complete 2-4 capsules daily
Secondary Support
a.
DHEA as directed to help manage cortisol levels
b.
Adrenal Tincture 1-2 droppers 3-6 times daily
c.
Endocrine Tincture 1-2 droppers 3-6 times daily
Section 4 Glucose
A. Glucose High
Primary Support
a.
Sugar Solve 2 capsules breakfast, 2 capsules dinner
to help maintain healthy glucose levels
b.
Pro Oranges 1 servings breakfast, 1 serving lunch to
help slow he release of glucose into the bloodstream
Secondary Support
a.
The Best Whey or Super Shake 1-2 servings daily
between meals to help maintain normal insulin levels
b.
Green Tea-70 1 capsule twice daily to help maintain
normal insulin levels
c.
Endocrine Tincture 1-2 droppers 3-6 times daily for
overall support of the endocrine system
Additional Considerations
a.
EnerDMG 1 tablet twice daily to aid the body in
glucose and fat metabolism
b.
TonaLean 1 softgel three times daily to help maintain
glucose levels
c.
Super B Complete 2-4 capsules daily
Section 4 Glucose
(continued)
B. Glucose Low
Primary Support
a.
The Best Whey or Super Shake 1-2 servings daily
between meals
b.
Frontier Fiber ½ hour before meals
Secondary Support
a.
Pro Oranges 1-2 servings daily
b.
AdrenaMax II 1 capsule each meal
c.
Super B Complete 2-4 capsules daily
Section 5
Cardiovascular
Primary Support
a.
Power Fuel 1-2 servings daily to increase heart
muscle strength and cardiovascular output
b.
Cardio Stack - 2 caps twice daily to enhance
cardiovascular health
c.
Power Q 600 or Power Q NOL or Power Q for overall
heart health
Secondary Support
a.
Omega 3D 3-4 softgels daily for heart and circulation
health
b.
Mag Complete 300 1 each meal
c.
E-400 1-2 softgels daily to help regulate blood
viscosity and circulation
d.
CircuCare Head & Heart 1-2 droppers 3-6 times
daily
Additional Considerations
a.
Seven Flowers BP 1-2 each meal for blood pressure
and/or stress issues
b.
CholestoCare II as directed for elevated cholesterol
c.
EnerDMG 1-2 daily for circulation and vascular
health
d.
Krill Oil 2-4 softgels daily to support cardiovascular
function and cholesterol levels
e.
Nattokin Plus 2-4 capsules daily between meals to
support healthy blood flow
f.
Section 6 Mood
Resveratrol-50 1 capsule twice daily for overall
cardiovascular output
Primary Support
a.
Mood Lift 2 capsules 1-2 times daily for depression
and sleep disturbances
b.
L-Theanine 1 capsule twice daily for stress
management, irritability and to promote relaxation
c.
Control as directed for stress, mood and sleep
Secondary Support
a.
Omega 3D 3-4 softgels daily
b.
Frontier Minerals 2 capsules breakfast, 2 dinner
c.
Super B Complete 2-4 capsules daily
Section 6 Mood
(continued)
Section 7
Lymphatic/Immune
Consider detox
program + Lymphatic
Herbal Tincture
NOTE: One’s lymphatic
system is the sewer
system of the body. For
optimum results, it is vital
to work on the elimination
organs that eliminate
lymph trash from the
body. The eliminative
organs include your
kidneys, colon &
skin. Adding support for
each of these organs will
greatly assist the
cleaning process of your
sewer (lymph) system. –
Consider adding one or a
combination of the
following: K&B Tincture,
Frontier Cleanse,
Immune Herbal
Tincture, etc.
Section 8
Kidney/Bladder
Additional Considerations
a.
D3
b.
Iodine Plus 1-3 capsules if low thyroid is suspected
c.
Relaxation & Sleep Tincture
Primary Support
a.
ImmunoMax II 1-2 tablets each meal
b.
EnerDMG 1-3 tables daily
c.
Ester C Plus 1-2 capsules each meal
Secondary Support
a.
N-AcetylCysteine 1 capsule three times daily
(especially for lung and mucus issues)
b.
Rad Free 2-6 capsules daily to help regulate
histamine
c.
D3
Primary Support
a.
K&B Tincture 1-2 droppers 3-6 times daily
b.
UT Cleanse as directed
Secondary Support
a.
Frontier Minerals 2 capsules twice daily
b.
Milk Thistle 1 capsule 3 times daily – has soothing
c.
Section 9
Musculoskeletal
Section 9
Musculoskeletal
(continued)
effect on kidney and bladder tissue
Mag Complete 300 as directed
A. Bones (questions 1-4)
Primary Support
a.
Super Cal Plus 2-4 tablets daily
b.
BetaZyme 1-2 capsules each meal – to support
proper stomach acid production to help with mineral
absorption
Additional Considerations
a.
Cal Mag Plus 1-2 scoops daily
b.
Ester C Plus 3 daily to support collagen production
to benefit teeth and bone health
c.
D3 for maintenance of bone density and calcium
utilization
d.
Frontier Minerals 2 capsules twice daily for bone
formation
e.
Resveratrol-50 1 capsule twice daily to support the
health of bone-building cells
B. Joints (questions 5-7)
Primary Support
a.
HA Plus 4 capsules daily
b.
Omega 3D 2 softgels daily
Additional Considerations
a.
Green Lipped Mussel as directed
b.
Ester C Plus 3 daily to support collagen production
c.
Krill Oil 2 softgels daily for joint health and comfort
d.
Rad Free 3 capsules daily to help restore collagen
e.
Green Tea-70 as directed for joint comfort
C. Muscles (questions 8-10)
Primary Support
a.
Frontier Minerals 2 capsules twice daily for proper
muscle contraction and relaxation
b.
MusseLAX - as directed
c.
Power Fuel 1 scoop 1-2 times daily for muscle
strength and recovery
Additional Considerations
a.
Cal Mag Plus 1-2 scoops daily for proper muscle
contraction and relaxation
b.
Mag Complete 300 as directed for proper muscle
contraction and relaxation
c.
Mood Lift 2 capsules 1-2 times daily to help
mood/stress
Section 10
Nervous System/
Brain
NOTE: Alkalization of the
body is essential for brain
and nerve
regeneration. Acidity
A. Central Nervous System (questions 1-5)
Primary Support
a.
Frontier Minerals 4 daily for healthy nerve function
b.
Neuro Tincture 1-2 droppers 3-6 times daily to
strengthen and rebuild nerve tissue of the body
c.
NeuroMax as directed for brain and nerve function
Additional Considerations
causes inflammation,
which leads to tissue
weakness and
deterioration.
a.
b.
L-Theanine 1 capsule twice daily for it’s calming
effects
Omega 3D 3-6 softgels daily
B. Brain (questions 6-10)
Primary Support
a.
Brain Boost II 3 capsules 1-2 times daily for
cognitive function, alertness & recall
b.
Neuro Tincture 1-2 droppers 3-6 times daily
Secondary Support
a.
EnerDMG 2 tablets daily for mental alertness and
brain function
b.
NeuroMax as directed for brain and nerve function
c.
L-Theanine 1 capsule twice daily – calming effects
Section 10
Nervous System/
Brain (continued)
Section 11 Male
Additional Considerations
a.
Omega 3D 3-6 softgels daily
b.
Krill Oil 2 softgels daily
c.
Pro Oranges 1-2 servings daily to support brain
function and mental alertness
d.
Pro Purples 1-2 servings daily to support mental
clarity and focus
Prostate
Primary Support
a.
PSA II 2 capsules 1-2 times daily
b.
EstroCleanse II as directed
c.
Frontier Flax 1 softgel each meal
Sex Drive
Primary Support
a.
Testo 180 2 capsules twice daily
b.
DHEA
c.
EstroCleanse II as directed
Section 12 Female
A. PMS
Primary Support
a.
EstroCleanse II as directed
b.
Mag Complete 300 as directed
c.
Super B Complete 2-4 capsules daily
d.
Endocrine Tincture 1-2 droppers 3-6 times daily
Secondary Support
a.
Frontier Flax 1 softgel each meal
b.
L-Theanine 1 capsule 1-2 times
stress/relaxation
c.
Frontier Minerals 2 capsules twice daily
d.
Cal Mag Plus 1 scoop twice daily
B. Ovarian Function/Hormonal Function
Primary Support
a.
EstroCleanse as directed
b.
DHEA
c.
Frontier Flax 1 softgel each meal
daily
–
Secondary Support
a.
Resveratrol-50 1 capsule twice daily
b.
Super Cal Plus 2-4 capsules daily for bone health
c.
DimPro 1 capsule twice daily
Section 13 Nutrients
A. Essential Fatty Acids
Frontier Flax 3-6 softgels daily
B. Protein/Amino Acids
The Best Whey 2 servings daily OR Amino 750
C. CoQ10
Power Q 600 or Power Q-NOL or Power Q or Power Q
gel
Section 13 Nutrients
(cont.)
D. Vitamin C
Ester C Plus 3 daily
E. Vitamin D
D3 1000 or D3 5000
F. Iodine
Iodine Plus 1-3 capsules daily OR Iodine Plus Liquid