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.
• 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.
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.
• Sex hormone imbalances.
– Women: Progesterone deficiency, estrogen excess, estrogen deficiency and androgen dominance.
– Men: Testosterone deficiency and estrogen excess.
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