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Orthomoleculartoronto.com


Brain Nutrition Quiz

Raymond J Pataracchia ND

If you are curious to find out what biochemical/physiological/nutrient profiles you have this Brain Nutrition Quiz
can help you identify distinct patterns. If you are interested, please print the form, fill it out legibly and fax or email it back to our clinic. All information is kept in strict confidence. We assess and convey quiz results by telephone as a courtesy to prospective clients.
Patient Name: _______________________________ Age: ___ Gender: M F Date: ________

Name of Party Requesting Information: _____________________________

Province/State/Country: ______________________ Phone # (with area code): __________________

Best time of day to reach you Monday-Thursday, 8:30am-5:00pm: _______________________

I provide permission for NMRC staff to process these results:


_______________________________

____________________________________
Guardian Signature (Required if patient is under 14 years old) Instructions: Please answer all questions as True or False. (60 questions, ~ 5 minutes)
1. I often have cold hands and/or feet.
T F
2. I am poor at adapting to temperature changes.
T F
3. I have less than two bowel movements per day or less than one foot of stool per day.
T F
4. I have a weight gain problem.
T F
5. I have hair loss.
T F
6. I have foggy thinking or poor memory.
T F
7. I am so sluggish that it interferes with my ability to do daily activities.
T F
8. I have a pale or fair complexion.
T F
9. I am a fairly heavy coffee drinker.
T F
10. I have a slow metabolism.
T F
11. I have a problem falling or staying asleep.
T F
12. I have allergic or environmental sensitivities.
T F
13. I have a mood, behaviour or psychotic condition.
T F
14. I have a nervous irritability.
T F
15. I have digestive pains, bloating or nausea.
T F
16. I have or have had metal dental fillings.
T F
17. My gums bleed frequently.
T F
18. I am a visual learner.
T F
19. My diet is mainly vegetarian.
T F
20. I use anti-psychotics, antibiotics, antacids, cortisone,Tagamet, Zantac or diuretics.
T F
21. I have bouts of depression or irritability.
T F
22. I have problems swallowing.
T F
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23. I feel worse taking birth control pills or after inserting my copper IUD (women only).
T F
24. I have a family history of heart disease or strokes.
T F
25. I have elevated cholesterol.
T F
26. I have osteoporosis (or osteopenia).
T F
27. My bowel movements sometimes resemble pellets of varying size.
T F
28. My bowel movements are unformed, irregular or contain undigested matter.
T F
29. I often feel anxiety in my stomach.
T F
30. I did not reach my developmental height or weight landmarks during childhood.
T F
31. I am hungry all the time.
T F
32. I have trouble putting on weight.
T F
33. I have feelings of unreality that have lasted greater than 6 months.
T F
34. I do not have a mental health problem.
T F
35. Time seems too slow or too fast or the world seems unreal.
T F
36. I have been a longstanding user of anti-psychotic medication.
T F
37. I have poor dream recall (2 or less times per week).
T F
38. Food tastes bland.
T F
39. I have weak knees.
T F
40. I have little or no appetite.
T F
41. I have white spots on my nails.
T F
42. I have frequent infections during cold season.
T F
43. I am irritable before meals or when I skip meals.
T F
44. I am tired after meals.
T F
45. I feel better when arguing or fighting.
T F
46. I have sugar cravings.
T F
47. I have an addiction to alcohol or illicit substances.
T F
48. I have abundant ears wax.
T F
49. I have dry skin (scalp, heels, hands, feet, etc.).
T F
50. I have small cherry red round bulges on the skin.
T F
51. I have a prominent history of bacterial infections.
T F
52. I have a history of anemia.
T F
53. I have depression or anxiety.
T F
54. I have a family history of schizophrenia.
T F
55. I have post-traumatic stress.
T F
56. Bowel movements pass often with pain or straining.
T F
57. I sometimes have muscle twitches or cramps in my calves, thighs, arms or face.
T F
58. I have a problem staying asleep or I sleep lightly.
T F
59. I have a problem falling asleep; my brain won’t shut off.
T F
60. I have a fast metabolism.
T F
Biochemical tendencies specific to over-all well-being and mental health are listed on our website ‘Top Nutrient Imbalances’ web page. For more reliable assessment of health status we recommend targeted lab testing (see ____________________________________________________________________________________________ NMRC, 441-20Eglinton Ave E, Toronto, ON, M4P 1A9; local 416-944-8824 or toll-free 1-877-678-4871; www.nmrc.ca
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Source: http://orthomoleculartoronto.com/userfiles/file/Brain%20Nutrition%20Quiz%20-%202013.pdf

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