Optimum Nutrition Questionnaire

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Your Optimum Supplement Program
Optimum Nutrition Questionnaire
Symptom Analysis
For each symptom that you experience often, score 1 point. Many symptoms occur more than once,
because they can be the result of many nutrient deficiencies. If you experience any of the symptoms in
bold type, score 2 points. The maximum score for each nutrient is 10 points. Put your score for each
nutrient in the box.
VITAMIN A
VITAMIN D
Mouth ulcers
Arthritis or osteoporosis
Poor night vision
Backache
Acne
Tooth decay
Frequent colds or infections
Hair loss
Dry flaky skin
Muscle twitching or spasms
Dandruff
Joint pain or stiffness
Thrush or cystitis
Weak bones
Diarrhea
YOUR SCORE
YOUR SCORE
VITAMIN B2
VITAMIN E
Bloodshot, burning, or gritty
Lack of sex drive
eyes
Exhaustion after light exercise
Sensitivity to bright lights
Easy bruising
Sore tongue
Slow wound healing
Cataracts
Varicose veins
Dull or oily hair
Poor skin elasticity
Eczema or dermatitis
Loss of muscle tone
Split nails
Infertility
Cracked lips
YOUR SCORE
YOUR SCORE
VITAMIN C
VITAMIN B3 (NIACIN)
Frequent colds
Lack of energy
Lack of energy
Diarrhea
Frequent infections
Insomnia
Bleeding or tender gums
Headaches or migraines
Easy bruising
Poor memory
Nose bleeds
Anxiety or tension
Slow wound healing
Depression
Red pimples on skin
Irritability

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