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HEALTH APPRAISAL QUESTIONNAIRE – COMPREHENSIVE


Select the number which best describes the frequency of your symptoms. If you do not know the answer to the question, leave it blank. When you are finished, please add the number of points in each section and enter the number on the Total Points line.
The score for YES is the number inside the parenthesis ( ).

0 = never or rarely1 = twice a week or less2 = three to six times a week3 = daily or several times a day

PART I GASTROINTESTINAL
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Section A HYPOACIDITY

Section C HYPERACIDITY

1. Stomach pain, burning, aching 1-4 hours after eating
2. Feeling hungry an hour or two after eating

3. Strong emotions, thought, smell of food aggravates stomach
4. Sense of fullness during and after meals
4. Heartburn, especially when lying down or bending forward
5. Poor appetite, disinterest in food
5. Heartburn due to spicy and fatty foods, chocolate, peppers, citrus, alcohol, caffeine
6. Offensive breath
6. Difficulty or pain when swallowing
7. Bad taste in mouth
7. Chest pain, difficulty breathing, lung infections
8. Partial loss of taste or smell
8. Constipation, difficult bowel movements
9. Difficulty swallowing
9. Black, tarry stool
10. Difficult bowel movements
10. Unexplained weight gain
Y (3)
11. Unintentional weight loss
11. Antacids, carbonated beverages, cream/milk/food relieve symptoms
Y (5)
12. History of anemia, unresponsive to iron
Y (5)
12. Digestive problems subside with rest and relaxation
Y (5)
13. Vegetarian (no eggs, dairy)
Y (3)
Total Points:

14. Picky eater
Y (3)
 
15. Spoon shaped nails
Y (3)
 
16. Sores in corner of mouth
Y (3)
 
17. Smooth tongue
Y (3)
 
Total Points:

 
  

Section B SMALL INTESTINE/PANCREAS

Section D COLON

1. Indigestion and fullness lasts 2-4 hours after eating
1. Lower abdominal pain, cramping and /or spasms
2. Pain, tenderness, soreness on left side under rib cage

2. Lower abdominal pain, relief by passing stool or gas
3. Bloated
3. Raw fruits, vegetables and stress aggravate bowel pain

4. Excessive passage of gas
4. Diarrhea (loose watery stool)
5. Abdominal cramps, aches
5. More than three bowel movements daily
6. Nausea and/or vomiting
6. Excessive gas and bloating
7. Dry, flaky skin; dry, brittle hair

7. Painful, difficult, straining during bowel movements
8. Difficulty gaining weight
8. Hard, dry or small stool

9. Weakness and fatigue
9. Extremely narrow stools
10. Specific foods/beverages aggravate indigestion
10. Alternating diarrhea/constipation
11. Roughage and fibre cause constipation
11. Mucus and pus in stool
12. Three or more large bowel movements daily

12. Feel bowels do not empty completely
13. Alternating constipation and diarrhea
13. Rectal pain or cramps

14. Stool poorly formed
14. Bright red blood following bowel movement
15. Stool – undigested food
15. Anal itching
16. Stool – greasy, shiny
16. Irritable, moody
17. Stool – yellowish, foul smelling

17.Rash under breast, armpit, around navel or groin area
Y (5)
18. Mucus in stool

18. Feel ill in damp, moldy settings or rainy weather
Y (3)
19. Black stool

Total Points:
20. Rectal spasms
 
21. Dark urine
 
22. Bone and back pain

 
23. Pounding heart

 
24. Iron deficiency anemia
 
Total Points:

 

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PART II DETOX METABOLISM

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Section A LIVER/GALLBLADDER/PANCREAS

Section B HYPOTHYROID

1. Moderate to severe pain under right side of ribcage

1. Tired, sluggish

2. Abdominal pain worse with deep breathing
2. Feel cold – hands, feet, all over

3. Bitter fluid repeats after eating
3. Tight sensations in neck
4. Bloated, full feeling

4. Difficult, infrequent bowel movements
5. Belching, heartburn, gas
5. Dryness, discoloration of skin, hair
6. Fatty foods cause indigestion

6. Thick, brittle nails
7. Nausea and/or vomiting
7. Puffy face, hands and feet

8. Feel restless, agitated, angry
8. Swollen upper eyelids
9. Unexplained itchy skin, worse at night
9. Eyeballs move involuntarily
10. Yellowish cast to skin, eyes
10. Muscles weak, cramp and/or tremble
11. Stool colour alternates from clay colour to normal brown

11. Slow mental processes, forgetfulness
12. General feeling of poor health
12. Slow heart beats

13. Fatigue, weakness, exhaustion
13. Abdominal swelling
14. Unable to concentrate, irritable, confused
14. Unsteady gait, movements
15. Aching muscles
15. Lack of interest in sex
16. Trembling hands

16. Gain weight easily
Y (5)
17. Weight gain due to water retention

17. Swelling of the neck
Y (5)
18. Swollen feet and/or legs

18. Outer third of eyebrow thins
Y (3)

19. Bleeding tendencies in gums, nose

19. Thinning hair on scalp, face and genitals
Y (3)
20. Loss of chest and armpit hair

20. Loss of appetite
Y (3)
21. Reddened skin, especially palms

21. Premenstrual tension
Y (3)
22. Dark urine, diminished flow

22. Infertility
Y (3)
23. Dry, flaky skin and/or hair
Y (3)
23. Excessive menstrual bleeding
Y (3)

24. Loss of appetite and weight
Y (3)

24. Absence of periods
Y (3)
25. Easily bruised
Y (3)
Total Points:
26. Thinning of pubic hair
Y (3)
  
27. Feeling of extreme dryness
Y (3)
  
28. Loss of skin elasticity
Y (3)
  
Total Points:

  

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PART III IMMUNE FUNCTION

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Section A HYPOADRENAL

Section C HYPERIMMUNITY

1. Progressive, mild fatigue after exertion or stress

1. Muscles fatigue quickly

2. General weakness
2. Moody, irritable, tired

3. Blurred vision, dizzy when rising

3. Severe fatigue
4. Depression

4. Severe joint pain, redness, swelling
5. Rapid mood swings

5. Chronic pain, stiffness throughout body
6. Irritable

6. Migraine headaches
7. Dark circles under the eyes

7. Specific food(s) worsen pain, inflammation, stiffness

8. Abdominal pain, indigestion

8. Sensitive to light (skin or eyes)
9. Bouts of nausea, vomiting

9. Dark circles under eyes
10. Diarrhea or constipation

10. Swollen – looking face or body
11. Blotchy skin (white patches)

11. Localised or general itching – eyes, ears, throat, nose, skin
12. Craving for salty foods

12. Clear, watery discharge from nose, eyes

13. Decreased appetite
Y (3)

13. Extreme dryness of eyes, nasal passages, mouth

14. Gradual weight loss
Y (3)

14. Sneezing

15. Tan skin, no sun
Y (3)

15. Cough or wheezing

16. Gradual loss of body hair
Y (3)

16. Moldy, damp environments trigger sickness

17. Black freckles on upper forehead, face, neck
Y (3)

17. Post nasal drip with certain foods

18. Sensitive to minor changes in weather and surroundings
Y (3)

18. Heart palpitations after eating certain foods

Total Points:
19. Weight loss, muscle weakness
Y (3)

  
20. Scalp hair falls out easily, in clumps
Y (3)

Section B HYPOIMMUNITY

21. Hair loss, entire body
Y (5)
1. Catch colds easily
22. Bruises easily
Y (3)

2. Infections – eyes, ears, nose, throat, lungs, skin

23. Nails loosened, pitted, discoloured
Y (3)
3. Diarrhea
Total Points:
4. Puffy face

  
5. Dark areas on cheeks, under eyes
  
6. Difficulty seeing at night
  
7. Eyes tear, bum, discharge
  
8. Ears continuously drain

  
9. Nasal congestion or discharge – thick, yellow, green
  
10. Sore throat or post-nasal drip

  
11. Cough with mucus
  
12. Inflamed or bleeding gums

  
13. Cold sores, few blisters
  
14. Gums swelling, bleeding
  
15. Unexplained weight loss of 4-5 kg in last three months
Y (3)
  
16. Lack of appetite
Y (3)
  
17. Nail discolourations
Y (3)

  
18. Bumpy skin on backs of arms
Y (3)

  
19. Wounds heal slowly
Y (3)

  
20. Hair is easily plucked out, or falls out, grows slowly
Y (3)

  
21. Lips are red and swollen
Y (3)

  
22. Tongue is red, swollen, raw looking
Y (3)

  
23. Impaired taste and smell
Y (3)

  
24. Neck, armpit, groin swelling
Y (5)

  
Total Points:
  

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PART IV CARDIOVASCULAR

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Section A ANAEMIA

Section C HEART

1. Sense of being overly tired

1. Feel jittery
2. Prolonged recovery after exercise

2. Heartburn that moves to neck, jaws, left shoulder and arm

3. Coldness, especially in hands and feet

3. First effort of the day causes pain around chest
4. Difficulty breathing, palpitations on exertion

4. Dizziness
5. Headache, dizziness, spots before eyes

5. Choking, smothering sensation
6. Irritable

6. Minor exertion exhausts
7. Forgetful, poor concentration

7. Heart pounds easily

8. Mild yellowing of eyes or skin

8. Heavy sweating (no exertion)

9. Ringing in ears
9. Mild or severe chest pain

10. Susceptible to infections
10. Difficulty catching breath, especially during exercise

11. Jaundice and dark urine

11. Wheezing or dry cough

12. Black stool (no iron supplements)
12. Heart palpitations – slow, rapid or irregular

13. Unusual cravings for clay, dirt, ice
13. Swelling in feet, ankles, legs, comes and goes

14. Fingernails are flattened, spoon-shaped, brittle, thin
Y (5)
14. Veins on neck are prominent

15. White patches on skin
Y (3)

15. High blood cholesterol
Y(10)
16. Pale lips, gums, eyelids, nail beds
Y (3)
Total Points:
17. Red, sore tongue
Y (3)
18. Mouth, throat, rectum ulcers
Y (3)

Section D CIRCULATION

19. Unusual bruising
Y (3)

1. Fluid retention

20. Spontaneous bleeding – nose, mouth, gums, rectum or vagina
Y (3)
2. Numbness, tingling, pricking sensation in hands, feet
21. Small red dots under the skin
Y (3)
3. Muscle pain in the calves or thighs when walking
22. Sores in corner of mouth
Y (3)
4. Muscle pain at rest
23. Smooth tongue
Y (3)
5. Cold feet
Total Points:
6. Headaches

 
7. Dizziness, everything spins

Section B BLOOD PRESSURE

8. Poor concentration

1. Nosebleeds
9. Slurred speech
2. Headache, typically in morning
10. Ringing in ears
3. Weak, fatigued, nervous
11. Brief moments of hearing loss
4. Ringing in ears
12. Nausea comes and goes quickly
5. Dizziness, drowsiness
13. Falling without known cause
6. Blushing – no apparent cause
14. Brief difficulty swallowing
7. Numbness, tingling in hands and feet
15. Brief difficulty speaking
8. Blurred vision
16. Stammering or twitching of tongue
9. Is blood pressure high?
Y(10)
17. Double vision
Total Points:
18. Difficulty understanding spoken or written word
19. Brief loss of muscular coordination in legs, arms
20. Inability to recognize persons or things that pass very quickly
21. One leg or arm shiny, hairless skin
Y(5)

22. Discoloured or blue toes
Y(5)

23. Open sores on feet and legs
Y(5)
24. Fingers and toes numb in response to cold weather, even when protected
Y(5)
Total Points:

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PART V GLUCOSE TOLERANCE

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Section A HYPOCLYCAEMIA

Section B HYPERGLYCAEMIA

Missing meals or fasting is associated with:

1. Excessive, frequent urination

1. Sudden anxiety associated with hunger

2. Increased thirst and appetite

2. Tingling sensation in hands
3. Blurred vision, failing eyesight

3. Palpitations
4. Fatigue, drowsiness
4. Feel shaky, jittery, tremors
5. Crave sweets, but eating sweets does not relieve craving
5. Weakness

6. Feel hungry for air (can’t get enough)
6. Profuse perspiration, clammy skin

7. Breath smells sweet
7. Nightmares
8. Depressed

8. Awake from sleep restless
9. Tingling, numbness, prickling sensation in extremities
9. Agitated, easily upset
10. Profuse sweating
10. Poor memory, forgetful
11. Dribble after voiding
11. Confused, disoriented

12. Impotency
12. Dizziness, feel faint
13. Dizziness when standing from sitting position

13. Feels cold, numb
14. Slurred speech
14. Mild headache
15. Unintentional weight loss
Y(3)
15. Blurred vision
16. Recurring persistent infection – bladder, skin or gums
Y(3)
16. Lack of coordination

17. Boils and leg sores
Y(3)

Total Points:

18. Very slow wound healing
Y(3)

19. Excessive weight gain
Y(3)

  
Total Points:

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PART VI LUNGS

PART VII KIDNEY/BLADDER

1. Weakness and fatigue

1. Retain fluid throughout body
2. Chest discomfort, pain
2. Mild lower back pain
3. Sudden breathing difficulty

3.Frequent urge to urinate, but only small amounts pass
4. Shortness of breath
4. Interruption of urine stream
5. Shallow breathing

5. Excessive urination
6. Noisy, rattling sounds when breathing in or out
6. Excessive urination at night
7. Cough – dry or moist

7. Burning when urinating
8. Rapid heartbeats
8. Frequent urination with urgency
9. Excessive perspiration

9. Rarely need to urinate
10. Anxiety, restlessness
10. Difficulty passing urine
11. Consistent low grade temperature

11.Dripping after urination
12. Bluish nails and lips
12. Can’t hold urine
13. Post nasal drip

13. Bloody, cloudy and /or darkened urine
14. Sputum thick, clear, yellow
14. Strong smelling urine
15. Sputum smells offensive

15. Joint and muscle pain
16. Bloody sputum
16. Tingling in joints
17 Bad breath

17. Dark circles under eyes
18. Wheezing
18. Gray, blackish caste to skin
19. Loud snoring

19. Back or leg pains associated with dripping after urination
Y(5)
20. Sleepy during day

20. Poor skin elasticity, dryness
Y(3)
21. Morning headache
Total Points:

22. Difficulty concentrating
 
23. Unexplained weight loss
Y(3)
 
24. Infections settle in lungs
Y(3)
 
25. Flu symptoms longer than 5 days
Y(3)

 
Total Points:
 

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PART VIII MALE

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Section A PROSTATE

Section B REPRODUCTION

1. Frequent or urgent need to urinate

1. Itchy patches around inner thigh and groin
2. Delayed, weak, or interrupted urine stream
2. Itching at night

3. Pain or burning upon urination
3. Painful testicles
4. Urge to urinate several times a night
4. Difficulty attaining and /or maintaining an erection
5. Rose coloured (bloody) urine
5. Low sexual drive
6. Difficulty urinating

6. Premature ejaculation
7. A sense of bladder fullness
7. Low energy level or stamina

8. Ejaculation causes pain
8. Inflammation on the head of penis
Y(5)

9. Blood in the semen
9. Genital and/or rectal rash or irritation
Y(5)
10. Lack of sex drive, impotency
10. Distorted nail growth
Y(3)

11. Impotency

11. Loss of pubic or armpit hair
Y(3)
12. Pain or fatigue in the legs or back
12. Infertile
Y(3)
13. Dripping after urination
13. Low sperm count, low sperm mobility
Y(3)
14. Increased straining with small amounts of urine passed
14. Unexplained weight gain
Y(3)
15. Anemia
Y(3)
15. Testicles appear smaller
Y(3)

Total Points:
16. Development of breasts or nipple tenderness
Y(3)

17. Feeling of heaviness or hardness in testicle
Y(3)

18. Sparse beard or slow hair growth
Y(3)

19. Decreased body hair
Y(3)

20. Fine wrinkling in corner of mouth or around eyes
Y(3)

Total Points:

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PART IX FEMALE

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Section A PMS

Section D DYSPLASIA/FIBROCYSTIC SYNDROME

Circle if you experience any of these symptoms within 3 days to two weeks (ovulation) prior to menstruation:
1. Painful, tender vaginal lumps
1. Insomnia

2. Clear, gray or yellow vaginal discharge

2. Abdominal bloating
3. Vaginal bleeding after intercourse or between periods
3. Breast tenderness, swelling
4. Burning or itching of the external genitalia
4. Breast lumps appear
5. Urgent, painful urination
5. Heart palpitations

6. Lower abdominal or back pain
6. Sweating and flushing
7. Heavy, watery and bloody vaginal discharge

7. Depressed, irritable, nervous
8. Heavy menstrual flow
8. Easily angered, resentful
9. Pelvic cramps
9. Easily overwhelmed
10.Thin, scant, white vaginal discharge
10. Nausea and/or vomiting

11. Greenish, yellow, or offensive discharge
11. Diarrhea or constipation
12. White, cheeselike discharge

12. Headache
13. Breast lumps or swelling
Y(10)
13. Food cravings, binge eating
14. Lumps hurt just before period
Y(5)
14. Back pain
15. Swelling under armpit
Y(5)

15. Numbness, tingling in hands and feet
16. Change in breast size, shape
Y(5)
16. Clumsiness
17. White or slightly bloody vaginal discharge, one week before period
Y(10)
17. Feeling hopeless, sad
Total Points:
18. Weight gain – water
Y(3)
19. Suicidal
Y(10)

Section E MENOPAUSE

Total Points:

1. Irregular menstrual cycle
2. Dry skin, hair, vagina

Section B OVARIAN DYSFUNCTION

3. Disinterest in sex
1. Vaginal dryness, pain
4. Mood swings, irritable
2. Painful intercourse

5. Depression, anxiety, nervousness
3. Engorged breasts

6. Craving for sweets, binge eating
4. Milk production (not nursing)
7. Headaches or dizziness

5. Disinterest in sex
8. Painful intercourse
6. Blurred vision
9. Sudden hot flushes
7. Headache
10. Spontaneous sweating
8. Acne and/or oily skin

11. Shortness of breath and/or heart palpitations
9. Aggressive feelings
12. Unpredictable vaginal bleeding

10. Overwhelming urges for sexual intercourse
13. Difficulty holding urine
11. Absence of menstrual flow for six or more months
Y(20)
14. Difficulty sleeping
12. Occasionally skip periods
Y(5)

15. Mental fogginess
13. Menstruation began after 16 years of age
Y(3)

16. Vaginal pain and/or itching
14. Breasts shrinking
Y(5)

17. Thin, scant, white vaginal discharge
15. Thinning pubic and armpit hair
Y(5)

18. Low back and/or hip pain
16. Unable to become pregnant
Y(10)

19. Breast tenderness, pain or tingling, pricking sensation
17. Miscarriage
Y(3)

20. Easily bruised, loss of skin tone
18. Excess facial hair
Y(5)

21. Thinning of armpit and pubic hair
Y(5)
19. Poor sense of smell
Y(3)

22. Breasts beginning to shrink, sag
Y(10)

20. Monthly abdominal pain without bleeding
Y(5)
23. Abnormal growth of hair above lip
Y(3)
Total Points:
Total Points:

Section C MENSTRUAL IRREGULARITIES

Circle if you experience any of these symptoms during your period.
1. Painful intercourse
2. Menstrual type pain between menses
3. Irregular interval between periods
Y(5)

4. Extended menses, greater than 32 days
Y(10)

5. Shortened menses, less than 24 days
Y(5)

6. Vaginal bleeding between periods
Y(10)

7. Vaginal discharge between periods
Y(5)

8. Pain during periods is becoming progressively worse
Y(5)

9. Pain, cramps
10. Unusual fatigue, can’t work

11. Irritable and depressed
12. Constipation and/or diarrhea
13. Lower abdominal pain, bloating
14. Nausea and /or vomiting

15. Lower backache
16. Pelvic and/or rectal pressure
17. Urinary difficulties
18. Frequent urination
Y(5)

19. Scanty blood flow
Y(3)
20. Heavy blood flow
Y(3)
Total Points:

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PART X MUSCULOSKELETAL

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Section A BONE INTEGRITY

Section C CONNECTIVE TISSUE

1. Generalised bone tenderness, achiness
1. Joint stiffness, soreness, swelling

2. Localised bone pain

2. Red, swollen, painful joints
3. Bone deformity or swelling
3. Joint stiffness improves with rest, worsens with movement
4. Shins hurt during or after exercise
4. Dry mouth

5. Low back or hip pain
5. Dry, painful eyes
6. Difficulty sitting straight
6. Joint stiffness worsens with rest, improves with movement
7. Walking difficulties, limp
7. Cracking joints
8. Crunching or creaking sounds when moving joints
8. Limp
9. Hands, feet, throat spasm or feel numb

9. Shooting, aching, tingling pain down the back of leg
10. Joint pain and stiffness – especially spine, hips, knees
10. Joint pain involves one or a few joints
11. Hearing loss, headaches, ringing in ears
11. Joint hurt when moving or when carrying weight

12. Cavities
Y(5)
12. Limited range of motion
13. Tooth loss due to gum disease
Y(5)
13. Difficulty standing up from seated position
14. Established bone loss
Y(10)

14. Walks slowly
15. Calcium deposits
Y(5)
15. Headaches
16. Spinal curvature
Y(10)
16. Difficulty chewing food or opening mouth
17. Recent loss of height
Y(10)
17. Intermittent pain, ache on one side of head, spreading to cheek, temple, lower jaw, ear, neck, shoulder
18. Bow legs
Y(5)
18. Numbness, prickling, tingling sensation in the neck, shoulder and arms
19. Stooped posture
Y(5)

19. Injure, strain, sprain easily
20. Hump at base of neck
Y(5)
20. Discomfort or pain in neck, shoulder or arm
21. Irregular patches of increased pigmentation
Y(3)
21. Involuntary muscle spasms

22. Unexplained bone fracture
Y(10)
22. Deliberate movement with hands is difficult

Total Points:
23. Red, painless skin lumps on elbows, knees, toes, ear, nose, back of scalp
Y(5)
24. Knobby overgrowths on the joints closest to the fingertips
Y(5)

Section B MUSCLE

25. Muscle loss around inflamed joint
Y(10)

1. Muscle aches and pains
26. Double jointed
Y(3)
2. Muscle stiffness, tension
27. One leg shorter than the other
Y(5)
3. Specific body points feel sore when pressed
Total Points:
4. Headaches

5. Fatigued, tired, sluggish

Section D NEUROLOGICAL

6. Difficulty sleeping
1. Head feels heavy

7. Feel unrefreshed upon waking
2. Light headedness, fainting
8. Difficulty speaking/swallowing
3. Ringing, buzzing in ears
9. Muscle cramps or spasm
4. Trembling hands
10. Muscles twitch or tremble – eyelids, thumb, calf muscle
5. Limbs feel too heavy to hold up

11. Irresistible urge to move legs
6. Loss of feeling in hands and/or feet (toes)
12. Legs move during sleep
7. Tingling sensation followed by numbness, spreads toward the centre of your body
13. Unpleasant crawling sensation inside the calves, while lying down
8. Unsteady gait, lose balance
14. Numbing, tingling sensation
9. Muscles feel weak

15. Excessive joint mobility
10. Weak grip with spasm and arm weakness
16. Unable to fully straighten or extend legs and/or arms
11. Exhaustion on slightest effort
17. Upper or lower back pain
12. Need for 10-12 hours sleep
18. Loss of muscle strength
Y(3)
13. Muscular weakness begins in leg and moves upward
19. Muscle loss, wasting
Y(3)
14. Difficulty walking, moving around, handsling small objects
Total Points:

15. Nervous, anxious
16. Convulsions

17. Confused, forgetful

18. Slowed or slurred speech
19. Difficulty breathing

20. Blurred vision
21. Eyelids droop

22. Impaired hearing, eyesight, sense of touch, smell, taste
Y(10)

23. Accident prone – trip, stumble, feel clumsy
Y(5)
Total Points:

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HEALTH HISTORY

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1. Check the following if you:

Diet often

Skip meals
Do not exercise regularly
Under excessive stress

Vegetarian
Exposed to chemicals

Smoke cigarettes – How many per week?
Drink alcohol – How many per week?

Drink coffee – How many per week?

Use sugar – How much each day?

2. Check any of the following medication you have taken in the last six months.
Antacids

Antidiabetic/Insulin
Cortisone/Anti-inflammatories
Laxatives

Aspirin/Tylenol
Heart Medications
Thyroid

Antibiotic/Antifungal
High Blood Pressure

Lithium

Ulcer Medications
Relaxants/Sleeping Tablets
Radiation

Chemotherapy

Antidepressants
Hormones

Oral Contraceptives
Recreational Drugs – Specify

Others

List nutritional/herbal supplements currently taking
Main health concern and other comments

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PART XI MOOD AND BEHAVIOUR

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Section A STRESS

Section D INSOMNIA

DO YOU…
DO YOU…
 
1. Feel stressed, nervous or tense

1. Have an overactive mind, or worry too much
2. Feel irritable or oversensitive
2. Have a fear of insomnia or sleep
3. Experience difficulty concentrating and loss of clear thought

3. Have a disruptive environment
4. Have coffee, tea, tobacco, sugar or other stimulants as a pick-me-up
4. Suffer from pain or discomfort
IN THE PAST TWO YEARSM HAVE YOU EXPERIENCED…
5. Eat chocolate or drink caffeine or alcohol with or after dinner
5. Divorce
Y(5)

6. Have difficulty falling asleep or staying asleep
6. Separation from partner
Y(4)

7. Often eat after 8 pm
7. Death in the family
Y(4)

Total Points:

8. Breaking the law
Y(4)

 
9. Bankruptcy
Y(4)

Section E HYPERACTIVITY/ADD

10. Moving house
Y(3)

DO YOU…

 
11. Losing or starting work
Y(3)
1. Find it difficult to keep still or are fidgety
Total Points:

2. Have a short attention span
3. Find it difficult to relax

Section B ANXIETY

4. Have or had learning difficulties
DO YOU…
5. Experience mental confusion or sluggishness
1. Experience worry or anxiety

6. Have allergies (especially to food)
2. Often feel nervous or tense

Total Points:

3. Feel overcautious or pessimistic
 
4. Have difficulty sitting quietly without fidgeting
 
5. Experience rapid heart beat or panic
 
6. Have coffee, tea, tobacco, sugar or other stimulants as a pick-me-up

 
Total Points:

 
 

Section C DEPRESSION

 
DO YOU…
 
1. Feel depressed
 
2. Experience a feeling of indifference (don’t care attitude)

 
3. Lose you sense of humor or take life too seriously

 
4. Feel like crying for no appropriate reason
 
5. Feel suicidal or wonder if life is worth living
 
Total Points:

 

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PART XII DERMATOLOGY/SKIN

PART XIII DETOX IMBALANCE

DO YOU HAVE…
ARE YOU SENSITIVE TO…
1. Acne
1. Sulphate (wine, dried fruit, or salad bar vegetables)
Y(2)

2. Psoriasis
2. Monosodium glutamate (MSG)
Y(2)
3. Eczema

3.Foods containing the preservative sodium benzoate or potassium benzoate
Y(2)
4. Dermatitis
4. Foods containing tyramine (red wine, cheese, bananas, or chocolate)
Y(2)
5. Warts
5. Foods or beverages containing caffeine
Y(2)
6.Tinea
6. Foods with onions or garlic in them
Y(2)

7. Dandruff
7. Chemicals such as fragrances, exhaust fumes, or strong odours
Y(2)
8. Rashes
8. Have you had a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents
Y(2)
9. Are you satisfied with the condition of your skin?
N
Y
9. Do you notice that you urine has a strong odour after eating asparagus
Y(2)

Total Points:
10. Do you regularly consume more than two alcoholic beverages per day
Y(2)

11. Do you feel ill after ingesting even small amounts of alcohol
Y(2)

12. Do you regularly consume more than four cups of coffee per day
Y(2)

13. Do you regularly use acetaminophen/paracetamol containing medications (e.g. Tylenol)
Y(2)

14. Do you use any hormone therapy in the form of birth control pills, progesterone, oestrogen, prostate medication etc.
Y(2)

15. Are you allergic to antibiotics such as penicillin, sulpha drugs, tetracyclines, etc.
Y(2)

16. Are you currently taking an antacid such as cimetidine (Tagamet) or ranitidine (Zantac)
Y(2)

17. Have you recently used or do you regularly use tobacco products
Y(2)

18. What is your blood type?

  
Total Points:

———————————————————————————————————————————-

PART XIV VITALITY/BODY IMAGE

———————————————————————————————————————————-

Section A VITALITY

Section B WEIGHT MANAGEMENT

DO YOU…
Where 0 is very satisfied and 4 is very concerned, rate how you feel about…
1. Experience inadequate energy or fatigue
1. The way my body looks
2. Suffer from Chronic Fatigue Syndrome
2. The way my body feels

3. Find it hard to get up or become motivated in the morning

3. My body fat
4. Often feel tired or overworked
4. My body muscle tone

5. Have difficulty staying awake

5. My strength
6. Experience mental confusion or sluggishness
6. My endurance
Total Points:

7. My flexibility
8. My attractiveness
9. My present weight

  
Total Points:

———————————————————————————————————————————-

PART XV WELLNESS

1. Are you female and over 50 years of age
2. Are you male and over 50 year of age
No

Yes
3. If female, are you planning to have a baby within the next 6 months, and therefore requiring preconceptual care
No

Yes
4. (Females only) Are you pregnant or breastfeeding
No

Yes

 

 

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