This form has been optimized for the following browsers:
 
Welcome to the NLA assessment.  It is comprised of 165 questions and will take approximately 20 minutes for you to complete.  At the end of the assessment please click submit button to send the completed form.

Click Here For Help

 
 Contact And Profile Information
 Please note that fields marked with an "*" are mandatory. All of these fields require an answer so that we can accurately determine your individual BMI
Area Code
  
*Age
*Height
 In
inches
* HPN  
 Please enter the the Hpn Number you were given by your practioner. (example: HPN:00-11-00-11-00)
  
*Weight
*Waist
 In
inches
* Confirm HPN  
                
*First Name  
                
*Your E-mail address
We require your e-mail address so that your personalized assessment can be sent to you. The confirmation of your email address is necessary for accuracy purposes.
*Confirm E-mail address

 Dietary Assessment
 
1.   On average, how often do you eat any of the following foods:
  • Ground beef, Steak, Hamburger
  • Luncheon meats (e.g., salami, bologna, hot dogs)
  • Bacon, Spare ribs, other pork products
  • Chicken wings?
2.   How often do you consume any of the following foods:
  • Cheeses with greater than 20% Milk Fat (MF) e.g., cheddar, mozzarella, Monterey Jack, brick, cream cheese, parmesan
  • Homogenized milk
  • Yogurt that is more than 1% MF
  • Regular Ice cream?
3.   Do you use cream in your coffee or tea on a daily basis?
4.   Do you routinely use butter on bread products such as toast, bagels, ?.
5.   Do you routinely use butter for cooking or on baked potatoes or vegetables?
6.   Do you use regular sour cream or high saturated fat salad dressings (e.g., French, Thousand Islands, etc.) more than once per week?
7.   What is your weekly whole egg consumption on average?
8.   How often do you eat fried foods? (deep-fried or pan-fried?)
9.   Do you choose poultry or fish in place of red meat, pork or fried foods in most situations?
10.   Are you a vegetarian or near vegetarian?
11.   How often do you consume any of the following:
  • 2% milk
  • margarine
  • yogurt that is 2% MF
  • low– fat sour cream
12.   How often do you consume any of the following foods:
  • pastries such as cakes, donuts, croissants, turnovers, cookies (3 or more)
  • non low fat muffins
  • rich desserts
  • premium ice cream
13.   On average, how often do you consume any high fat snack foods: e.g., potato chips, nachos, any type of fried chips, cheesies, regular chocolate bars, other chocolate treats?
14.   How often do you consume sugary carbohydrate snacks & drinks:
  • regular soft drinks
  • licorice, jujubes, hard candies, gummy bears, ?.
  • sweet, refined breakfast cereals, rice crispy squares
15.   On average, how many servings of garden vegetables do you consume on a daily basis? (e.g., carrots, tomatoes, broccoli, cauliflower, peppers, romaine lettuce, spinach, collard greens, kale)
16.   On average, how many servings per day do you consume of any starchy carbohydrate foods, such as pasta, rice, beans, peas, corn, oatmeal, etc.?
17.   On average, how many servings of fruit do you have per day? Note: 1 serving = 1 whole fruit (e.g., apple, orange, peach), 1/2 cup chopped fruit (e.g.), fruit salad), 8 oz. fruit juice
18.   What is your average alcohol consumption? Note: 1 drink = 1 beer, or a 5-oz. glass of wine, or 1 cocktail
19.   How often, on average, do you consume any food or drinks containing high amounts of artificial sweeteners and/or food additives, colours, artificial flavours?

Examples of these food/drink items: diet and regular soft drinks, potato chips, nachos, cheesies, corn chips, licorice, jujubes, gummy bears, gelatins, ice cream, fruit ices, sherbet, rice crispy squares, granola bars, or other similar types of snacks.
20.   Do you take a multiple vitamin and mineral supplement daily?
 Exercise Participation Screening Questionnaire
 
21.   Do any of the following statements apply to you:
    • Your doctor has informed you that you have heart trouble or a heart condition of some kind
    • You frequently have pain in your chest or have had chest pain recently
    • You often feel faint or have spells of severe dizziness that are not caused by an innner ear condition
    • You have been informed that you have high blood pressure
    • You are over the age of 65 and are unaccustomed to vigourous exercise
22.   Do you perform endurance or aerobic exercise for a minimum of 30 minutes three or more times per week, on average? (jogging, power walking, stationary cycling, stairmaster, elliptical machine, stepmill, rowing machine, swimming, squash, racquetball, handball, etc.?)
23.   Do you perform a strength training program a minimum of two sessions per week (e.g. weight training, martial arts, body pump exercise class, calisthenics using body weight for resistance or using a Thera-Ball, Ashtanga Yoga, boxercise, gymnasitics, etc.?)
24.   Do you perform flexibility exercises a minimum of twice per week (e.g. stretching, yoga, etc.?)
 Vitamin and Mineral Status
 
25.   Do you eat fewer than 5 fruit and vegetable servings per day, on average?
26.   Do you often experience a scaly, flaky, seborrheic condition at the outer nose margins above the lips?
27.   Do you have soft nails or do they chip, crack or peel easily, and/or are brittle or contain ridges (not smooth)?
28.   Are there white spots on your fingernails?
29.   Have you noticed many small red spots on your skin?
30.   Do you consume more than three alcoholic beverages per week, on average?
31.   Do you drink more than two cups of coffee or caffeinated tea (of any kind) per day, on average?
32.   Are you a smoker?
33.   Has your skin been damaged by sunlight and/or do you use a tanning bed more than once per month?
34.   On a scale of one to five, what level of stress do you experience in your daily life?

Use the following guideline: 1 = minimal stress; 5 = a very high stress level
35.   Do you often experience cracks at the corners of your lips?
36.   Do you often experience a sore or burning tongue?
37.   Have you experienced a reduced ability to taste food?
38.   Do your gums bleed easily?
39.   Do you bruise easily?
40.   Are you a slow healer from bruises and cuts?
41.   Do you feel chronically tired?
42.   Do you have irregular or erratic eating patterns?
43.   Are you on a weight loss or calorie restricted diet?
44.   Do you feel run down and/or are you experiencing a weakened state of immunity? (e.g., frequent colds, sore throat, or known to have an immune-compromised state)
45.   Does your hair fall out easily, and/or is it dry and brittle and/or does it lack optimal luster and sheen?
 Medications Affecting Your Nutrient Status
 
46.   Do you regularly use laxatives?
47.   

Do you regularly use antibiotics or have you undergone long-term antibiotic therapy within the past two years such as:

 
  • Azithromycin
  • Cephalosporins
  • Clarithromycin
  • Erythromycin
  • Penicillins
  • Gentamycin
  • Neomycin
  • Sulfamethoxazole
  • Sulfasalazine
  • Trimethoprim/Sulfamethoxazole
  • Tetracycline
  • Tobramycin etc.?
48.   Do you regularly use Cholesterol - lowering drugs? (any of the following): - Cholestyramine - Colestid - Clofibrate (Atromid-S®) - Questran® - Welchol® - Colestripol (Colestid®) etc.?
49.   Do you regularly use Anti-gout drug called Colchicine?
50.   Do you regularly use Steroid hormones, i.e., Cortisone, Prednisone?
51.   Do you regularly use Aspirin for arthritis or any other reason (or other nonsteroidal anti-inflammatory drugs), such as: - Novo-Difenac - Diclofenac (Voltaren®, Cataflam®) - Diclofenac and misoprostol (Arthrotec®) - Etodolac (Lodine®) - Flurbiprofen (Ansaid®) - Ibuprofen (Motrin® and others) - Ketoprofen (Orudis®, Oruvail®) - Ketorolac (Toradol®) - Nabumetone (Relafen®) - Naproxen (Anaprox®, Naprosyn®) - Oxaprozin (Daypro®) - Piroxicam (Feldene®) - Salsalate (Disalcid®, Salflex®) - Sulindac (Clinoril®) - Celecoxib (Celebrex®) - Rofecoxib (Vioxx®) - Meloxicam (Mobic®) etc.?
52.   Do you regularly use Antacids such as: - Magnesium or Aluminum hydroxide containing antacid - Calcium Rich Rolaids® - Maalox® - Mylanta® - Sodium Bicarbonate (Alka-Seltzer®) - Cimetidine (Tagamet®) - Esomeprazole (Nexium) - Famotidine (Pepcid®) - Lansoprazole (Prevacid®) - Omeprazole (Prilosec®) - Panteloc - Pariet rabeprazole sodium - Ranitidine (Zantac®) etc.?
53.   Do you regularly use oral contraceptives?
54.   Do you regularly use Sedatives / Barbiturates such as: - Phenobarbital (Luminal®)?
55.   Do you regularly use Estrogen Replacement such as: - Premarin® - Cenestin® etc.?
56.   Do you regularly consume Caffeine products? e.g., caffeinated coffee, tea, espresso
57.   Do you smoke on a regular basis?
58.   Do you regularly use Antidepressants such as: - Citalopram (Celexa®) - Escitalopram oxalate (Lexapro®) - Fluoxotine (Prozac®) - Fluvoxamine (Luvox®) - Paroxetine (Paxil®) - Sertraline (Zoloft®) - Amytryptiline® - Clomipramine HCL (Anafranil) - Elavil®, - Imipramine® etc.?
59.   Do you regularly use Amphetamines (i.e adderall, cylert, ritalin, benedrine, dexedrine)?
60.   Do you regularly use - Levodopa? - Sinemet® - Carbidopa-Levodopa etc.?
61.   Do you regularly use Anti-convulsants such as: - Carbamazepine - Dilantin® - Epival ( Divalproex sodium) - Phenobarbital - Phenytoin - Primidone - Tegretol® - Topiramate (Topamax®) - Valproic acid etc.?
62.   Do you regularly use Digoxin or Digitalis?
63.   Do you regularly use Indomethacin (Indocin®) etc.?
64.   Do you regularly use diuretics such as: - Thiazides (Bendroflumethiazide (Naturetin®), Benzthiazide (Exna®) - Chlorothiazide (Diuril®) - Chlorthalidone (Hygroton®) - Hydrochlorothiazide (Esidrix®, HydroDiuril®, Microzide™) - Hydroflumethiazide (Diucardin®) - Indapamide (Lozol®) - Irbesartan-hydrochlorothiazide (Avalide) - Methyclothiazide (Enduron®) - Metolazone (Zaroxolyn®, Mykrox®) - Polythiazide (Renese®) - Quinethazone (Hydromox®) - Trichlormethiazide (Naqua®) - Amiloride (Midamor®) - Apo-Triazide (Triamterene – hydrochlorothiazide) - Hydrochlorothiazide and Spironolactone mixed form (Aldactazide®, Alazide®) - Spironolactone (Aldactone®) - Triamterene (Dyrenium®) - Bumetanide (Bumex®) - DIOVAN HCT - Ethacrynic acid (Edecrin®) - Furosemide (Lasix®) - Irbesartan-hydrochlorothiazide (Avalide) - Torsemide (Demadex®) etc.?
65.   Do you regularly use medication for High Blood Pressure, using Antihypertensive ACE-Inhibitor drugs, such as: - Benazepril (Lotensin®) - Captopril (Capoten®) - Enalapril (Vasotec®) - Inhibace (Cilazapril), - Lisinopril (Prinivil®, Zestril®), Moexipril (Univasc®) - MONOPRIL (fosinopril sodium tablets), Perindopril (Coversyl) - Quinapril (Accupril®) - Ramipril (Altace®) - Trandolapril (Mavik®) etc.?
66.   Do you regularly use High Blood Pressure, using Antihypertensive Beta-blockers, such as: - Acebutolol (Sectral®) - Atenolol (Tenormin®) - Betaxolol (Kerlone®) - Bisoprolol (Zebeta®, Monocor®) - Labetalol (Normodyne®, Trandate®) - Metoprolol (Lopressor®) - Nadolol (Corgard®) - Propranolol (Inderal®) - Sotalol (Betapace®) - Timolol (Blocadren®) etc.?
67.   Do you regularly use Statin Cholesterol-lowering drugs such as: - Statin drugs: Atrovastatin (Lipitor®) - Ezetrol - Fluvastatin (Lescol®) - Lovastatin (Mevacor®) - Rosuvastatin (Crestor®) - Simvastatin (Zocor®) etc.?
 Personal Health History: Cardiovascular Risk Factors
 
Do you have any of the following health conditions:
  
68.   High cholesterol levels?
69.   High triglyceride levels?
70.   High blood pressure?
 Personal Health History: Cancer
 
Do you currently have or have you ever had any of the following:
  
71.   Breast cancer?
72.   Colon or rectal cancer?
73.   Any other cancer?
74.   Leukoplakia (precancerous condition of the mouth)?
75.   Are you interested in knowing about scientifically-based nutrition, lifestyle and supplementation practices that can lower your risk of cancer, in general?
 Personal Health History: Gastrointestinal Health
 
Do you currently suffer from:
  
76.   Stomach or intestinal ulcers?