General Nutritional (Nutrient) Deficiency Symptom Checklist

• Suspicion of nutrient malabsorption*
• 123
• Rate from 1 to 3
• Anemia*
• 123
• Rate from 1 to 3
• Decreased immune function*
• 123
• Rate from 1 to 3
• Decreased energy*
• 123
• Rate from 1 to 3
• Do you experience hormonal imbalance?*
• 123
• Rate from 1 to 3
• Do you have a history of any of these chronic conditions? Heart disease, obesity, diabetes, cancer, celiac disease, IBS, and/ or chronic fatigue syndrome*
• YesNo

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