Magnesium Status Questionnaire - Shamarie Body and Mind Therapies

Magnesium Status Questions

1 = Almost never ; 2 = sometimes ; 3 = Fairly often; 4 = Very often.

1. Drink alcohol every day or more than 7 alcoholic drinks per week.

1 2 3 4

2. Strenuous exercise or training more than 3 times per week (running, sports, gym, etc.)

1 2 3 4

3. More than 3 coffees per day

1 2 3 4

4. High sugar-containing foods daily

1 2 3 4

5.Eat processed food or junk food daily

1 2 3 4

6.Consume a diet high in fatty foods (fried foods, butter, hamburgers, bcon, ice-cream, cheese)

1 2 3 4

7.A diet low in green leafy vegetables, seeds and nut (less than one serve every day)

1 2 3 4

8. Consume soft drinks/fizzy drinks daily

1 2 3 4

9. Frequently have undigested food or fat in your stools (more than 3 times per week)

1 2 3 4

1). Chronic headaches or migraines

1 2 3 4

2). Asthma

1 2 3 4

3). Diabetes

1 2 3 4

4.) Gaucoma

1 2 3 4

5.) Osteoporosis

1 2 3 4

6.) Chronic kidney disease

1 2 3 4

7.) High blood pressure

1 2 3 4

8.) An overactive thyroid or underactive thyroid

1 2 3 4

9.) An endocrine condition such as hyperaldosteronism or Hyperpathyrodism

1 2 3 4

10.) Very fast heart beats, irregular heartbeats or arrhythmia (or have experienced these symptoms in the last 12 months)

1 2 3 4

11.) Chronic intestinal disease - Ulcerative colitis, Crohn's disease or irritable bowel syndrome

1 2 3 4

12.) Frequent diarrhoea or constipation

1 2 3 4

13.) PMS or menstrual cramps

1 2 3 4

14.) Frequent Lethargy or fatigue

1 2 3 4

15.) Known parasites

1 2 3 4

16.) Currently pregnant

1 2 3 4

17.) Recently pregnant (last 12 months)

1 2 3 4

18.) Breastfeeding or recently breastfed for longer than 12 months

1 2 3 4

19.) Have diagnosed Haemochromatosis (iron overload)

1 2 3 4

20.) In a previous pregnancy had high blood pressure or pre-eclampsia

1 2 3 4

21.) Recent traumatic stress, physical or emotional (in the last 12 months)

1 2 3 4

1.) Taking Digitalis (digoxin)

1 2 3 4

2.) Taking any kind f diuretic medication

1 2 3 4

3.) Known to have low blood potassium

1 2 3 4

4.) Known to have Vitamin D deficiency

1 2 3 4

5.) Taking Calcium supplements regularly without Magnesium

1 2 3 4

6.) Medically diagnosed malnutrition

1 2 3 4

7.) Taking Iron or Zinc suppements regularly withou Magnesium

1 2 3 4

8.) Told by your practitioner you have an acid/alkali imbalance

1 2 3 4

9.) Told or kow you have had exposure to heavy metals such as Mercury Cadmium or Aluminium or Lead

1 2 3 4

10.) Frequently use antibiotics (more than 3 courses in the last 6 months)

1 2 3 4

11.) Currently on steriod medication (e.g. Prednisolone, Symbacort, Cortisone)

1 2 3 4

12.) Taking Oral contraceptives

1 2 3 4

13.) Had recent radition therapy or exposure (in last 12 months)

1 2 3 4

1). Easily startled by sounds or people

1 2 3 4

2). Muscle spasms in hands or feet

1 2 3 4

3). Difficulty sleeping

1 2 3 4

4). Irritability, or being easily provoked

1 2 3 4

5). Feeling restless or agitated

1 2 3 4

6). Smal muscle twitching around your eyes, facial muscles

1 2 3 4

7). Convulsions

1 2 3 4

8). Experience long or intense periods of stress

1 2 3 4

9). Shakiness or tremor in your hands

1 2 3 4

10). Muscle cramps

1 2 3 4

11). Chronic lack of interest indifference or apathy

1 2 3 4

12). Poor memory

1 2 3 4

13). Experience physical or mental fatigue

1 2 3 4

14). Loss of concentration

1 2 3 4

15). Anxiety

1 2 3 4

16). Mood Swings

1 2 3 4

17). Depression for no apparent reason

1 2 3 4

18). Feelings of disorientation as to time or place

1 2 3 4

19). Experience emotional stress

1 2 3 4

20). Feelings that people are against you

1 2 3 4

21). Cold hands or feet

1 2 3 4

22). Numbness in face, hands, or feet

1 2 3 4

23). Experience tingling or pins and needles anywhere in your body

1 2 3 4

24). Loss of libido

1 2 3 4

Magnesium Status Questions

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