Brain Health and Nutrition Assessment Form™ (BHNAF)

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Name *

Age *

Email *

Phone Number *

Please circle the appropriate number on all questions below.

0 as the least/never to 3 as the most/always.

Low brain endurance for focus and concentration

Clear selection

Cold hands and feet

Clear selection

Must exercise or drink coffee to improve brain function

Clear selection

Poor nail health

Clear selection

Fungal growth on toenail

Clear selection

Must wear socks at night

Clear selection

Nail beds are white instead of pink

Clear selection

The tip of the nose is cold

Clear selection

Irritable, nervous, shaky, or light-headed between meals

Clear selection

Feel energized after meals

Clear selection

Difficulty eating large meals in the morning

Clear selection

Energy level drops in the afternoon

Clear selection

Crave sugar and sweets in the afternoon

Clear selection

Wake up in the middle of the night

Clear selection

Difficulty concentrating before eating

Clear selection

Depend on coffee to keep going

Clear selection

Fatigue after meals

Clear selection

Sugar and sweet cravings after meals

Clear selection

Need for a stimulant, such as coffee, after meals

Clear selection

Difficulty losing weight

Clear selection

Increased frequency of urination

Clear selection

Difficulty falling asleep

Clear selection

Increased appetite

Clear selection

Always have projects and things that need to be done

Clear selection

Never have time for yourself

Clear selection

Not getting enough sleep or rest

Clear selection

Difficulty getting regular exercise

Clear selection

Feel that you are not accomplishing your life’s purpose

Clear selection

Dry and unhealthy skin

Clear selection

Dandruff or a flaky scalp

Clear selection

Consumption of processed foods that
are bagged or boxed

Clear selection

Consumption of fried foods

Clear selection

Difficulty consuming raw nuts or seeds

Clear selection

Difficulty consuming fish (not fried)

Clear selection

Difficulty consuming olive oil, avocados,
flax seed oil, or natural fats

Clear selection

Difficulty digesting foods

Clear selection

Constipation or inconsistent bowel movements

Clear selection

Increased bloating or gas

Clear selection

Abdominal distention after meals

Clear selection

Difficulty digesting protein-rich foods

Clear selection

Difficulty digesting starch-rich foods

Clear selection

Difficulty digesting fatty or greasy foods

Clear selection

Difficulty swallowing supplements or large bites of food

Clear selection

Abnormal gag reflex

Yes

Clear selection

Brain fog (unclear thoughts or concentration)

Yes

Clear selection

Pain and inflammation

Yes

Clear selection

Noticeable variations in mental speed

Yes

Clear selection

Brain fatigue after meals

Clear selection

Brain fatigue after exposure to chemicals, scents,
or pollutants

Clear selection

Brain fatigue when the body is inflamed

Clear selection

Grain consumption leads to tiredness

Clear selection

Grain consumption makes it difficult to focus
and concentrate

Clear selection

Feel better when bread and grains are avoided

Clear selection

Grain consumption causes the development
of any symptom

Clear selection

A 100% gluten-free diet

Yes

Clear selection

A diagnosis of celiac disease, gluten sensitivity,
hypothyroidism, or an autoimmune disease

Yes

Clear selection

Family members who have been diagnosed with
an autoimmune disease

Yes

Clear selection

Family members who have been diagnosed
with celiac disease or gluten sensitivity

Yes

Clear selection

Changes in brain function with stress, poor sleep,
or immune activation

Clear selection

A loss of pleasure in hobbies and interests

Clear selection

Feel overwhelmed with ideas to manage

Clear selection

Feelings of inner rage or unprovoked anger

Clear selection

Feelings of paranoia

Clear selection

Feelings of sadness for no reason

Clear selection

A loss of enjoyment in life

Clear selection

A lack of artistic appreciation

Clear selection

Feelings of sadness in overcast weather

Yes

Clear selection

A loss of enthusiasm for favorite activities

Clear selection

A loss of enjoyment in favorite foods

Clear selection

A loss of enjoyment in friendships and relationships

Clear selection

Inability to fall into deep, restful sleep

Clear selection

Feelings of dependency on others

Clear selection

Feelings of susceptibility to pain

Clear selection

Feelings of worthlessness

Clear selection

Feelings of hopelessness

Clear selection

Self-destructive thoughts

Clear selection

Inability to handle stress

Clear selection

Anger and aggression while under stress

Clear selection

Feelings of tiredness, even after many hours of sleep

Clear selection

A desire to isolate yourself from others

Clear selection

An unexplained lack of concern for family and friends

Clear selection

An inability to finish tasks

Clear selection

Feelings of anger for minor reasons

Clear selection

A decrease in visual memory (shapes and images)

Clear selection

A decrease in verbal memory

Clear selection

Occurrence of memory lapses

Clear selection

A decrease in creativity

Clear selection

A decrease in comprehension

Clear selection

Difficulty calculating numbers

Clear selection

Difficulty recognizing objects and faces

Clear selection

A change in opinion about yourself

Clear selection

Slow mental recall

Clear selection

A decrease in mental alertness

Clear selection

A decrease in mental speed

Clear selection

A decrease in concentration quality

Clear selection

Impaired mental performance

Clear selection

An increase in the ability to be distracted

Clear selection

Need coffee or caffeine sources to improve
mental function

Clear selection

Need coffee or caffeine sources to improve
mental function

Clear selection

Feelings of nervousness or panic for no reason

Clear selection

Feelings of dread

Clear selection

Feelings of a “knot” in your stomach

Clear selection

Feelings of being overwhelmed for no reason

Clear selection

Feelings of guilt about everyday decisions

Clear selection

A restless mind

Clear selection

An inability to turn off the mind when relaxing

Clear selection

Disorganized attention

Clear selection

Worry over things never thought about before

Clear selection

Feelings of inner tension and inner excitability

Clear selection

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