Throughout the book entitled, Look At Me, I’m Talking to You, the author referred to a questionnaire as being a useful tool in helping determine one’s possible nutrient deficiencies. This Body Language Questionnaire, as it was called, consists of almost 250 questions that, when answered in the affirmative, are related to symptoms of deficiency of vitamins, minerals, and enzymes. It was used only as a tool to determine probable nutritional deficiencies.
A few questions do require a doctor’s diagnosis. These questions would ask if you have arthritis, diabetes, or heart disease. There was no minimum age for taking the questionnaire; however, parents would have to assist young children in answering questions.
Initially, the answers were entered into a computer for evaluation; the results were printed and given to the client from which was done an in-depth nutritional consultation. The client also had the option of taking the results and discussing them with their doctor, nutritionist, health care counselor, or anyone else of his or her choosing.
When the questionnaire was first introduced in 1979, the suggested fee for the test results and an in depth consultation was twenty-five dollars. Since a consultation cannot be provided, we are offering the questionnaire only at no cost. It would be up to you to discuss the results with your health care practitioner.
Please be cautioned: Do not be tempted to make your own diagnosis and to render your own treatment as indicated by the test results. Always confer with a professional health care provider.
This report is not designed or intended to diagnose, prognosticate, treat or prescribe for any disease or condition of the body or to be used as a form of therapy for any disease or condition. Its sole purpose is to act as and educational guide to nutritional deficiencies, using known nutritional deficiency signs as an evaluation base. Any questions regarding suggestions given should be discussed with your health care practitioner.
INSTRUCTIONS: In completing this form, place a check mark next to each question you answer "yes". Do not mark if they do not apply. Do not "agonize" over a question. If it is unclear or questionable ignore the question and go to the next. Upon completion, total the checked questions for each section and refer to answer sheet at the end of the questionnaire.
SECTION 1 Vitamin A
Do you have?
*Frequent colds or respiratory infections (more than 3 a year)?
*Goose bumps on the back of arms or on top of the legs?
*Difficulty seeing in dim light, have poor night vision, or eye sensitivity to glare, sunlight or bright lights?
*An inability to adjust eyes when entering a dark room?
*Acne, pimples, blackheads or warts?
*A predisposition to infections of the throat and lungs?
*Infections of the bladder, kidney, urinary tract or burning sensation when urinating?
*Sinus problems?
SECTION 2 Vitamin B-1
Do you have?
*Slow heart beat, fast heart beat, or heart palpitations?
*Pain, or hurt all over, but can’t pinpoint an area?
*Forgetfulness, poor memory, or short attention span?
*Loss of weight or appetite?
*Poor coordination or loss of ankle or knee jerk reflexes?
*Vague fears about many things?
SECTION 3 Vitamin B-2
Do you have?
*Cracks or sores in the corner of your mouth?
*Red lines in the whites of your eyes?
*Red, itchy eyes or have a burning sensation?
*Oily hair or oily skin in the T-factor around your nose?
*A sensation of sand in your eyes?
*Conjunctivitis or ‘pink eyes’?
*Cataracts?
*A red/purple colored, shiny, sore or swollen tongue?
SECTION 4 Vitamin B-3
Do you have?
*Burning sensation in hands or feet?
*Numbness in hands or feet?
*Canker sores or small ulcers in the mouth?
*Schizophrenia? (doctor diagnosed)
*Suffer from irritability, anxiety or depression?
*Itchy, red or inflamed skin?
*Dermatitis or chapping of the back of hands?
*Indigestion or diarrhea?
SECTION 5 Vitamin B-6
Do you have?
*Dizziness or irritability?
*Motion sickness (boat, car, or amusement rides)?
*Nausea?
*Kidney stones?
*Edema (swelling of hands, feet, ankles)?
*An inability to remember your dreams?
*An inability to close your hands into a tight fist?
*Soreness, tenderness, weakness of thumb muscles?
*Female: Pregnancy nausea?
SECTION 6 Vitamin B-12
Do you have?
*A beefy red colored or sore tongue?
*Hallucinations, paranoia, or delusions?
*A tendency towards being confused, disorientated, or easily agitated?
*Jerking of limbs?
*A tendency to stammer?
*Depression, irritability, or moodiness?
*Lost your incentive in life, or are apathetic?
*Numbness, tingling, soreness or weakness in hands or feet?
SECTION 7 Pantothenic Acid
Do you have?
*Chronic headaches?
*A sudden feeling of dizziness?
*Lightheadedness or dizziness when getting up out of a lying or sitting position?
*Burning sensations of the feet or hands?
*Unusually large or dilated pupils in your eyes?
*Doctor diagnosed arthritis?
*Doctor diagnosed hypoglycemia?
*An exceptionally stressed feeling?
*Allergies?
*Rapid heart beat upon slight exertion?
SECTION 8 PABA
Do you have?
*A tendency to sunburn easily?
*Skin sensitivity to the sun?
*White patches on the skin, loss of pigment, or vitiligo?
SECTION 9 Biotin
Do you have?
*Poor appetite?
*Hair loss?
*Inflamed, dry, scaly, or shiny skin?
*Insomnia?
*Nausea?
SECTION 10 Choline
Do you have?
*Eczema?
*Difficulty losing weight?
*Bleeding ulcer?
*High cholesterol levels?
*High blood pressure?
SECTION 11 Folic Acid
Do you have?
*Sprue or intestinal mal-absorption? (doctor diagnosed)
*Excess pigmentation of skin?
*Anemia? (doctor diagnosed)
*Apathy or depression?
SECTION 12 Vitamin C
Do you have?
*Inflamed gums?
*Bleeding gums when you brush your teeth?
*Loose teeth or loose dental fillings?
*Cold, flu, or viruses (more than 3 a year)?
*Ruptured blood vessels in either eye?
*Cuts, sores or wounds that heal slowly?
*Cuticles that tear easily?
*Nosebleeds or bruise easily?
*Cartilage problems or fragile bones?
SECTION 13 Vitamin D
Do you have?
*Osteomalacia or osteoporosis? (doctor diagnosed)
*Constipation, insomnia, muscular cramps or nervousness?
*Burning in the mouth or throat?
*Poor bone development, bowlegs, or knock-knees?
SECTION 14 Vitamin E
Do you have?
*Muscular type problems such as swelling or wasting away?
*Hemolytic anemia? (doctor diagnosed)
*Female: Menstrual discomfort?
*Male: Loss of sex drive?
SECTION 15 Hydrochloric Acid
Do you have?
*Indigestion or sourness 2-3 hours after eating?
*A heavy, full, loggy feeling after eating a heavy meat meal?
*More than the usual gas, belching or burping after a meal?
*Abdominal bloating or distention after eating?
*A lost taste or craving for meat?
*A tongue that is usually coated white or do you suffer from halitosis?
*Anemia, is being treated, but not making much progress?
*Sour stomach?
*Burning sensation in the stomach?
SECTION 16 Calcium
Do you have?
*Leg cramps during sleep or exercise?
*Painful cramping of feet or toes?
*Difficulty in falling asleep?
*Tooth decay?
*Frequent toothaches?
*Teeth that are crowded with poor placement in the mouth?
*Nervousness or are you irritable?
*Unusual sensitivity to noise?
*Female: Excessive, lengthy, painful menses?
SECTION 17 Potassium
Do you have?
*Unusual thirst?
*Swelling of the ankles or hands?
*Slow, rapid or irregular heartbeat?
*Muscle fatigue…weakness…twitching…tremors?
*Unusually sore or stiff muscles after exercising?
*Dry skin (unusually so)?
*Salt retention?
SECTION 18 Sodium
Do you have?
*Dehydration, dry tongue, or lack of thirst?
*Cravings for salt?
*Muscle cramps?
*Difficulty digesting meat and other protein-rich foods?
*Potassium depletion?
SECTION 19 Magnesium
Do you have?
*Nervous tics or twitches particularly around the eyes?
*Loose teeth?
*Teeth sensitive to hot or cold?
*Muscle spasms, tremors, convulsions or seizures?
*Excessive body odor?
*Cravings for chocolate?
*Bone spurs?
*Anxiety, confusion, disorientation or irritability?
*Mental depression or apathy?
*Hyper-sensitivity to noise?
SECTION 20 Iron
Do you have?
*Pale skin or very pale palms of hands?
*Fingernails very light in color, flat, or concave (spoon shaped)?
*A very pale inner side of lower eyelid?
*Cravings for ice, or ice-eating?
*Tiredness most of the time?
*A tendency to get tired very easily?
*Shortness of breath?
SECTION 21 Manganese
Do you have?
*Tendonitis or tennis elbow?
*Athletic type injuries, strained knees, or elbows?
*Myasthenia gravis, multiple sclerosis or nervous degeneration? (doctor diagnosed)
*Muscular weakness?
*Loss of ligament tone or strength?
*Allergies?
SECTION 22 Iodine
Do you have?
*Dry hair?
*Brittle fingernails?
*Eyes sensitive to light?
*Slow mental reaction time?
*Enlarged thyroid gland?
*Stuffy nose?
*Sties on the eyelids?
*High cholesterol in the blood?
SECTION 23 Zinc
Do you have?
*Wounds or cuts that heal slowly?
*Lost sense of smell or taste?
*Stretch marks?
*Sterility or are impotent?
*Loss of appetite or anorexia?
*Acne?
*Slow growing hair or nails?
*White spots on fingernails?
*Male: Prostatitis?
SECTION 24 Copper
Do you have?
*Weak hair and nails?
*Fungus infection of the nails?
SECTION 25 Selenium
Do you have doctor diagnosed?
*Cancer?
*Weakened heart tissue, cardio-myopathy?
*Cystic fibrosis?
*Muscular degeneration, muscular dystrophy?
SECTION 26 Chromium
Do you have?
*Intolerance to alcohol?
*Glucose intolerance, hypoglycemia or diabetes?
*High cholesterol in the blood?
SECTION 27 Protein
Do you have?
*Cataracts?
*Excessive fluid retention in the extremities (hands or feet)?
*Poor co-ordination?
*Low resistance to disease including colds, flu and infections?
*Dull, dry, sparse, loose and falling out hair?
*Low hormone levels?
*Premature aging?
SECTION 28 Enzymes
Do you have?
*Nausea, bloating or indigestion caused by eating fat, greasy or spicy foods?
*Stools that appear yellow, clay-colored, or has a foul odor?
*A doctor prescribed low salt diet?
*Oily skin on nose and forehead?
*Recurring bad breath, bad taste in mouth, excess body odor?
*Bloating, gas, or other distress when eating onions, radishes, cucumbers, or cabbage?
SECTION 29 Pituitary
Do you have?
*An abdominal ‘apron’ of fat?
*Headaches affecting one side of the head?
*A painful left little finger?
*Infertility or impotence?
*Feelings that dominate over logic?
*Changeable or moody temperament?
*Feelings of inadequacy?
*A tendency to be overweight from the waist up or overweight from the waste down?
*Female: Lost menstrual function?
SECTION 30 Liver
Do you have?
*Jaundiced (yellowish) skin and eyes? (doctor diagnosed)
*Light colored stools?
*Skin itching?
*Intolerance to fatty food, cooking oils, spicy foods?
*Intolerance to alcohol?
*Brownish spots on skin (liver spots)?
*Elevated cholesterol/triglycerides…or too low?
SECTION 31 Thyroid
Do you have?
*A tendency to gain weight easily, or fail to lose on diets?
*Cold hands and/or feet?
*Low body temperature, less than 98.6, especially at bedtime?
*Low blood pressure?
*Constipation or have less than one bowel movement daily?
*Missed heart beats or heart palpitation?
*Diminished sex drive?
*High cholesterol or hypoglycemia?
*Dry, scanty, brittle, dull, lusterless, or lifeless hair?
*Dry, flaky, rough skin?
*An intolerance to heat or cold?
*Female: Prolonged, heavy menstrual bleeding or shorter menstrual cycle?
SECTION 32 Adrenal
Do you have?
*Unusual craving for salt?
*Cold sweats or goose bumps?
*Tendency to be negative?
*A voice that rises to a higher pitch or is ‘lost’ during stress, arguments or confrontations?
*Blood pressure fluctuations?
*Emotional upsets causing complete exhaustion requiring you to lie down?
*Dizziness or light-headiness when going from a lying position to a standing position?
*Tightness or ‘lump’ in the throat, or throat hurts when emotionally disturbed?
*An intolerance to cigarette smoke or extreme sensitivity to odors and/or noise?
*Paranoia, phobias, or are easily frustrated?
*Clenching/grinding of teeth during sleep?
SECTION 33 Pancreas
Do you have?
*Peculiar sensations in hands or feet (tingling, burning, sharp jabs, numbness, etc)?
*Constant, intense thirst?
*Big appetite?
*Hands which are moist without obvious cause?
*A tendency to urinate large amounts, more than 2 quarts daily?
*Urine that contains sugar or breath that smells sweet?
*Rapidly failing vision?
*Cuts and abrasions which heal slowly?
*A tendency towards fainting, blackouts, or convulsions?
*A tendency to be moody with marked ups or downs, elations or depression, hyperactivity or laziness?
*Vague, unrelated complaints which can be relieved by eating only to return with a vengeance?
*Suffer from shakiness or feel cold or sweaty?
SECTION 34 Thymus
Do you have?
*Flu and/or infections frequently?
*Swollen glands in armpit, groin, or tonsils?
*A tendency to look older than your chronological age?
*Soreness on both sides of your neck at shoulder level?
*More than the usual number of cavities?
SECTION 35 Ovarian (female)
Female: Do you have?
*Lost or diminished sex drive?
*Or had your uterus or ovaries removed?
*Uncomfortable menstrual periods?
*Nervousness or depression before periods?
*Menopausal symptoms including hot flashes, nervousness or depression?
*An inability to have children because of sterility?
Prostate (male)
Male: Do you have?
*Difficulty urinating including starting, burning or continuity?
*Back or leg pain associated with above?
*Need to urinate more than twice during the night?
*Prostatitis or prostate surgery?
*A lost or diminished sex drive?
INSTRUCTIONS: Typically, if one checks one or two question in a section, it was considered as being low in that area. If three or more questions were checked in a section, it was considered as being very low and the addition of that nutrient, whether it is through diet or supplementation, should be contemplated.
Again, please be cautioned: Do not be tempted to make your own diagnosis and to render your own treatment as indicated by the test results. Always confer with a professional health care provider. |
