Main

Brain Health and Nutrition Assessment Form™ (BHNAF)

Your Name (required)

Your Email (required)

Age

Sex

Date

Please select the appropriate number on all questions below.
0 as the least/never to 3 as the most/always.

SECTION 1
• Low brain endurance for focus and concentration
• Cold hands and feet
• Must exercise or drink coffee to improve brain function
• Poor nail health
• Fungal growth on toenails
• Must wear socks at night
• Nail beds are white instead of pink
• The tip of the nose is cold

SECTION 2
• Irritable, nervous, shaky, or light-headed between meals
• Feel energized after meals
• Difficulty eating large meals in the morning
• Energy level drops in the afternoon
• Crave sugar and sweets in the afternoon
• Wake up in the middle of the night
• Difficulty concentrating before eating
• Depend on coffee to keep going

SECTION 3
• Fatigue after meals
• Sugar and sweet cravings after meals
• Need for a stimulant, such as coffee, after meals
• Difficulty losing weight
• Increased frequency of urination
• Difficulty falling asleep
• Increased appetite

SECTION 4
• Always have projects and things that need to be done
• Never have time for yourself
• Not getting enough sleep or rest
• Difficulty getting regular exercise
• Feel that you are not accomplishing your life’s purpose

SECTION 5
• Dry and unhealthy skin
• Dandruff or a flaky scalp
• Consumption of processed foods that are bagged or boxed
• Consumption of fried foods
• Difficulty consuming raw nuts or seeds
• Difficulty consuming fish (not fried)
• Difficulty consuming olive oil, avocados, flax seed oil, or natural fats

SECTION 6
• Difficulty digesting foods
• Constipation or inconsistent bowel movements
• Increased bloating or gas
• Abdominal distention after meals
• Difficulty digesting protein-rich foods
• Difficulty digesting starch-rich foods
• Difficulty digesting fatty or greasy foods
• Difficulty swallowing supplements or large bites of food
• Abnormal gag reflex YesNo

SECTION 7
• Brain fog (unclear thoughts or concentration) YesNo
• Pain and inflammation YesNo
• Noticeable variations in mental speed YesNo
• Brain fatigue after meals
• Brain fatigue after exposure to chemicals, scents, or pollutants
• Brain fatigue when the body is inflamed

SECTION 8
• Grain consumption leads to tiredness
• Grain consumption makes it difficult to focus and concentrate
• Feel better when bread and grains are avoided
• Grain consumption causes the development of any symptoms
• A 100% gluten-free diet YesNo

SECTION 9
• A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease YesNo
• Family members who have been diagnosed with an autoimmune disease YesNo
• Family members who have been diagnosed with celiac disease or gluten sensitivity YesNo
• Changes in brain function with stress, poor sleep, or immune activation

SECTION 10
• A loss of pleasure in hobbies and interests
• Feel overwhelmed with ideas to manage
• Feelings of inner rage or unprovoked anger
• Feelings of paranoia
• Feelings of sadness for no reason
• A loss of enjoyment in life
• A lack of artistic appreciation YesNo
• Feelings of sadness in overcast weather
• A loss of enthusiasm for favorite activities
• A loss of enjoyment in favorite foods
• A loss of enjoyment in friendships and relationships
• Inability to fall into deep, restful sleep
• Feelings of dependency on others
• Feelings of susceptibility to pain

SECTION 11
• Feelings of worthlessness
• Feelings of hopelessness
• Self-destructive thoughts
• Inability to handle stress
• Anger and aggression while under stress
• Feelings of tiredness, even after many hours of sleep
• A desire to isolate yourself from others
• An unexplained lack of concern for family and friends
• An inability to finish tasks
• Feelings of anger for minor reasons

SECTION 12
• A decrease in visual memory (shapes and images) YesNo
• A decrease in verbal memory
• Occurrence of memory lapses
• A decrease in creativity
• A decrease in comprehension
• Difficulty calculating numbers
• Difficulty recognizing objects and faces
• A change in opinion about yourself
• Slow mental recall

SECTION 13
• A decrease in mental alertness
• A decrease in mental speed
• A decrease in concentration quality
• Slow cognitive processing
• Impaired mental performance
• An increase in the ability to be distracted
• Need coffee or caffeine sources to improve mental function

SECTION 14
• Feelings of nervousness or panic for no reason
• Feelings of dread
• Feelings of a “knot” in your stomach
• Feelings of being overwhelmed for no reason
• Feelings of guilt about everyday decisions
• A restless mind
• An inability to turn off the mind when relaxing
• Disorganized attention
• Worry over things never thought about before
• Feelings of inner tension and inner excitability