A Clinical Nutritionist’s Do-It-Yourself Health Questionnaire: Complete it and ‘See What Turns Up’

Clinical Nutritionist Blake Graham, practicing in Perth, Western Australia, specializes in nutritional and environmental medicine therapies for those with chronic medical conditions, such as ME/CFS, fibromyalgia, and environmental illness. His website – www.nutritional-healing.com.au

Over the past 7 years Blake Graham has designed and refined a very detailed 16-page questionnaire to help assess the large array of potential factors which may be contributing to a person’s symptoms. As he states, “all illness is multi-factorial, and it is very logical to at least consider all of these variables when assessing a patient.”

To see a copy of this questionnaire, last updated Feb 13, 2011, click here (pdf file).

Print it off, carefully fill it in, and see what turns up. It may provide a much more complete and revealing health record for both you and your professional healthcare team – and perhaps new clues as to helpful tests and opportunities to improve your health support plan.

Factors Assessed Via This Questionnaire

1. Illness triggers or precipitating factors.

2. Family history / genetic predisposition.

3. Sleep.
• Lack of adequate sleep.
• Sleep apnea.
• Sleep disruption.
• Restless leg syndrome.
• Circadian rhythm imbalance.

4. Dietary inadequacies and excesses.

5. Post infectious state/chronic infection.

6. Blood sugar imbalances.
• Diabetes mellitus.
• Hypoglycemia.

7. Nutrient imbalances.
• Essential fatty acid deficiencies.
• Copper excess.
• Magnesium deficiency.
• Iron deficiency.
• Vitamin D deficiency.
• Zinc deficiency.

8. Pyroluria (stress-exacerbated genetic condition that causes anxiety, depression, withdrawal).

9. Impaired liver detoxification.

10. Gastrointestinal – intolerances/allergies/maladigestion.
• Celiac disease/gluten intolerance.
• Fat malabsorption.
• Stomach acid deficiency (hypochlorhydria).
• Food allergies/intolerances – general.
• Fructose malabsorption.
• Lactose intolerance.

11. Gastrointestinal – microbiology.
• Intestinal bacterial imbalance (dysbiosis).
• Intestinal yeast overgrowth.
• Intestinal parasites.

12. Environmental exposures.
• Electromagnetic radiation exposure.
• Environmental mold.
• Environmental chemicals.
• Heavy metals.

13. Neurotransmitter imbalances.
• Serotonin deficiency.
• Dopamine/noradrenaline deficiency and excess.
• Acetylcholine deficiency.
• Endorphin deficiency.
• GABA deficiency.

14. Psycho-social stress/emotional issues.

15. Hormone imbalances.
• Hypo-adrenal.
• Hypo-thyroid.
• Sex hormone imbalances.
– Women: Progesterone deficiency, estrogen excess, estrogen deficiency and androgen dominance.
– Men: Testosterone deficiency and estrogen excess.

Blake Graham, BSc (Honours), AACNEM
Clinical Nutritionist
Perth, Western Australia
Phone/Email: See Contact Page

To sign up for Blake Graham’s free Nutritional Healing e-newsletter, click here.

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