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

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

  1. uxordepp says:


    This looks like a very thorough questionnaire, but I wonder if the “Pollen Season” they suggest (October through January)should not be adjusted for the northern hemisphere to something like April to August?

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