Nutritional Survey | Dr. Sanda Moldovan

Do you currently experience any of the following conditions:

If you experience two more symptoms from the list below you might want to ask your doctor about the SpectraCell MicroNutrient Test.

Do you experience fatique?

Yes
No

Do you experience anxiety?

Yes
No

Do you have loss of weight or appetite?

Yes
No

Do your hands tingle?

Yes
No

Do you experience muscle cramping?

Yes
No

Do you experience vomiting?

Yes
No

Does your heart flutter?

Yes
No

Do you have skin conditions?

Yes
No

Are you experiencing depression?

Yes
No

Do you have weight gain?

Yes
No

Do you experience bruising?

Yes
No

Do you have reduced muscle mass?

Yes
No

Do you have diarrhea?

Yes
No

Are you experiencing hair loss?

Yes
No

Do you have digestive problems?

Yes
No

Do you experience numbness?

Yes
No

Do you experience muscle weakness?

Yes
No

Do you experience nausea?

Yes
No

Do you experience constipation?

Yes
No

Do you experience slow wound healing?

Yes
No

Do you experience skin rashes?

Yes
No

Do you have a low libido?

Yes
No

Do you experience low energy levels?

Yes
No

Supplements

Are you currently taking nutritional supplements?

Yes
No

Where are they purchased?

Which brand?

How many times a day?

What supplements are you using?

multivitamin
antioxidants
fish oils
calcium
others:

Other Supplements:

Where do you obtain information on nutritional supplements?

news media
friends and family
your doctor
internet
other:

Other:

Are you currently taking prescription medication?

Yes
No

Please list:

How would you classify this statement: "All vitamins/nutritional supplements are created equal."

True
False
Don't know

Cardiovascular Health Survey

Do you have a family history of heart disease or diabetes?

Yes
No

Have you been diagnosed with heart disease or diabetes?

Yes
No

Do you take cholesterol-lowering medications?

Yes
No

Have you been diagnosed with Metabolic Syndrome?

Yes
No

Are you overweight?

Yes
No

Do you have low HDL-good cholesterol?

Yes
No

Do you have high LDL-the bad cholesterol?

Yes
No

Do you have high triglycerides?

Yes
No

Do you currently experience any of the following conditions: