Health Checks is a free service from Genesis Health Institute to help you better assess the status of your health and to point you to areas of potential concern. Please download the Nutritional Assessment Questionnaire and the Nutritional Assessment Questionnaire Graph by clicking on the links below. Complete the questionnaire by circling the appropriate answer to each question. Score each section by adding together each answer you circled with a response that was greater than zero. Write the score for each section, beginning with Section I in Part II (at the bottom of the first page of the questionnaire). Make sure to skip Section 12 if you are female and section 13 if you are male; so if you are female, the score for the “Male only” section would be zero. If you are male, the score for Section 13 “Female Only” would be zero.
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On the graph, circle the number that corresponds to the score you placed at the bottom. Any scores in the “High Priority” zone indicate issues that you should immediately discuss with your physician. “Moderate Priority” scores indicate potential areas of concern. Your goal is to be in the “Low priority” zone for all major organ systems.
The Nutritional Assessment Questionnaire is only a health screening tool. It is not intended to diagnose or treat any condition. Please consult your physician with any health concerns as this questionnaire does not substitute for medical advise.
Nutritional Assessment Questionnaire
NAQ- Manual Assessment Form