HEALTH APPRAISAL - COMPREHENSIVE

NAME _____________________________________________________ DATE _________________

CIRCLE 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 in the Total Points box. The points for YES is the number inside the parenthesis ( ).

(0) never or rarely     (1) twice a week or less    (2) Three to six times a week     (3) daily


PART I

Section A

1.  Indigestion 0 1 2 3
2.  Excessive belching, burping and/or bloating 0 1 2 3
3.  Gas immediately following a meal 0 1 2 3
4.  Sense of fullness during and after meals 0 1 2 3
5.  Poor appetite, disinterest in food 0 1 2 3
6.  Offensive breath 0 1 2 3
7.  Bad taste in mouth 0 1 2 3
8.  Partial loss of taste of smell 0 1 2 3
9.  Difficult bowel movements 0 1 2 3
10.  Difficulty swallowing 0 1 2 3
11.  Unintentional weight loss N     Y(5)
12.  History of anemia, unresponsive to iron N     Y(5)
13.  Vegetarian (no eggs, dairy) N     Y(3)
14.  Picky eater N     Y(3)
15.  Spoon shaped nails N     Y(3)
16.  Sores in corner of mouth N     Y(3)
17.  Smooth tongue N     Y(3)
 
Total Points __________

 

 

Section C

1.  Stomach pain, burning, aching 1-4 hrs. after eating 0 1 2 3
2.  Feeling hungry an hour or two after eating 0 1 2 3
3.  Strong emotions, thought, smell of food aggravates stomach 0 1 2 3
4.  Heartburn, especially when lying down or bending forward 0 1 2 3
5.  Heartburn due to spicy and fatty foods, chocolate, peppers, citrus, alcohol, caffeine 0 1 2 3
6.  Difficulty or pain when swallowing 0 1 2 3
7.  Chest pain, difficulty breathing, lung infections 0 1 2 3
8.  Constipation, difficult bowel movements 0 1 2 3
9.  Black, lorry stool 0 1 2 3
10.  Unexplained weight gain N     Y(5)
11.  Temporary relief from antacids, carbonated beverages, cream/milk/food N     Y(5)
12.  Digestive problems subside with rest and relaxation N     Y(5)
 
Total Points __________

Section B

1.  Indigestion and fullness lasts 2-4 hours after eating 0 1 2 3
2.  Pain, tenderness, soreness on left side under rib cage 0 1 2 3
3.  Bloated 0 1 2 3
4.  Excessive passage of gas 0 1 2 3
5.  Abdominal cramps, aches 0 1 2 3
6.  Nausea and/or vomiting 0 1 2 3
7.  Dry, flaky skin, dry brittle hair 0 1 2 3
8.  Difficulty gaining weight 0 1 2 3
9.  Weakness and fatigue 0 1 2 3
10.  Specific foods/beverages aggravate indigestion 0 1 2 3
11.  Roughage and fiber causes constipation 0 1 2 3
12.  Three or more large bowel movements daily 0 1 2 3
13.  Alternating constipation and diarrhea 0 1 2 3
14.  Stool poorly formed 0 1 2 3
15.  Stool - undigested food 0 1 2 3
16.  Stool - greasy, shiny 0 1 2 3
17.  Stool yellowish, foul smelling 0 1 2 3
18.  Mucus in stool 0 1 2 3
19.  Black stool 0 1 2 3
20.  Rectal spasms 0 1 2 3
21.  Dark urine 0 1 2 3
22.  Bone and back pain 0 1 2 3
23.  Pounding heart 0 1 2 3
24.  Iron deficiency anemia 0 1 2 3
 
Total Points __________

 

 

Section D

1.  Lower abdominal pain, cramping and/or spasms 0 1 2 3
2.  Lower abdominal pain relief by passing stool or gas 0 1 2 3
3.  Raw fruits, vegetables and stress aggravate bowel pain 0 1 2 3
4.  Diarrhea (loose watery stool) 0 1 2 3
5.  More than three bowel movements daily 0 1 2 3
6.  Excessive gas and bloating 0 1 2 3
7.  Painful, difficult, straining during bowel movements 0 1 2 3
8.  Hard, dry or small stool 0 1 2 3
9.  Extremely narrow stools, thin stool 0 1 2 3
10.  Alternating diarrhea / constipation 0 1 2 3
11.  Mucus and pus in stool 0 1 2 3
12.  Feeling that bowels do not empty completely 0 1 2 3
13.  Rectal pain or cramps 0 1 2 3
14.  Bright red blood following bowel movement 0 1 2 3
15.  Anal itching 0 1 2 3
16.  Irritable, moody 0 1 2 3
17.  Rash under breast, armpit, around navel or groin area N     Y(5)
18.  Feel ill in damp, moldy settings or rainy weather N     Y(3)
 
Total Points __________
 
PART II

Section A

1.  Moderate to severe pain under right side of rib cage 0 1 2 3
2.  Abdominal pain worse with deep breathing 0 1 2 3
3.  Bitter fluid repeats after eating 0 1 2 3
4.  Bloated, full feeling 0 1 2 3
5.  Belching, heartburn, gas 0 1 2 3
6.  Fatty foods cause indigestion 0 1 2 3
7.  Nausea and/or vomiting 0 1 2 3
8.  Feel restless, agitated, angry 0 1 2 3
9.  Unexplained itchy skin worse at night 0 1 2 3
10.  Yellowish cast to skin, eyes 0 1 2 3
11.  Stool color alternates from clay colored to normal brown 0 1 2 3
12.  General feeling of poor health 0 1 2 3
13.  Fatigue, weakness, exhaustion 0 1 2 3
14.  Unable to concentrate, irritable, confused 0 1 2 3
15.  Aching muscles 0 1 2 3
16.  Trembling hands 0 1 2 3
17.  Weight gain due to water retention 0 1 2 3
18.  Swollen feet and or legs 0 1 2 3
19.  Bleeding tendencies in gums, nose 0 1 2 3
20.  Loss of chest and armpit hair 0 1 2 3
21.  Reddened skin, especially palms 0 1 2 3
22.  Dark urine, diminished flow 0 1 2 3
23.  Dry, flaky skin and/or hair N     Y(3)
24.  Loss of appetite and weight N     Y(3)
25.  Easy bruising N     Y(3)
26.  Thinning of pubic hair N     Y(3)
27.  Feeling of extreme dryness N     Y(3)
28.  Loss of skin elasticity N     Y(3)
 
Total Points __________

 

 

Section B

1.  Tired, sluggish 0 1 2 3
2.  Feel cold, hands, feet, all over 0 1 2 3
3.  Tight sensation in neck 0 1 2 3
4.  Difficult, infrequent bowel movements 0 1 2 3
5.  Dryness, discoloration skin, hair 0 1 2 3
6.  Thick, brittle nails 0 1 2 3
7.  Puffy face, hands and feet 0 1 2 3
8.  Swollen upper eyelids 0 1 2 3
9.  Eyeballs move involuntarily 0 1 2 3
10.  Muscles weak, cramp, and/or tremble 0 1 2 3
11.  Slow mental processes, forgetfulness 0 1 2 3
12.  Slow heart beats 0 1 2 3
13.  Abdominal swelling 0 1 2 3
14.  Unsteady gait, movements 0 1 2 3
15.  Lack of interest in sex 0 1 2 3
16.  Weight gain easily N     Y(5)
17.  Swelling of the neck N     Y(5)
18.  Outer third of eyebrow thins N     Y(3)
19.  Thinning hair on scalp, face and genitals N     Y(3)
20.  Loss of appetite N     Y(3)
21.  Premenstrual tension N     Y(3)
22.  Infertility N     Y(3)
23.  Excessive menstrual bleeding N     Y(3)
24.  Absence of periods N     Y(3)
 
Total Points __________
 
PART III

Section A

1.  Progressive, mild fatigue after exertion or stress 0 1 2 3
2.  General weakness 0 1 2 3
3.  Blurred vision, dizzy when rising 0 1 2 3
4.  Depression 0 1 2 3
5.  Rapid mood swings 0 1 2 3
6.  Irritable 0 1 2 3
7.  Dark circles under the eyes 0 1 2 3
8.  Abdominal pain, indigestion 0 1 2 3
9.  Bouts of nausea, vomiting 0 1 2 3
10.  Diarrhea or constipation 0 1 2 3
11.  Blotchy skin (white patches) 0 1 2 3
12.  Craving for salty foods 0 1 2 3
13.  Decreased appetites N     Y(3)
14.  Gradual weight loss N     Y(3)
15.  Tan skin, no sun N     Y(3)
16.  Gradual loss of body hair N     Y(3)
17.  Black freckles on upper forehead, face, neck N     Y(3)
18.  Sensitive to minor changes in weather and surroundings N     Y(3)
 
Total Points __________

Section B

1.  Catch colds easily 0 1 2 3
2.  Infections - eye, ears, nose throat, lungs, skin 0 1 2 3
3.  Diarrhea 0 1 2 3
4.  Puffy face 0 1 2 3
5.  Dark areas on cheeks, under eyes 0 1 2 3
6.  Difficulty seeing at night 0 1 2 3
7.  Eyes tear, burn, discharge 0 1 2 3
8.  Ears, continuously drain 0 1 2 3
9.  Nasal congestion or discharge thick, yellow, green 0 1 2 3
10.  Sore throat or post-nasal drip 0 1 2 3
11.  Cough with mucus 0 1 2 3
12.  Inflamed or bleeding gums 0 1 2 3
13.  Cold sores, fever blisters 0 1 2 3
14.  Gums swelling, bleeding 0 1 2 3
15.  Unexplained weight loss of 10 pounds in last three months N     Y(3)
16.  Lack of appetite N     Y(3)

 

 

Section B (continued)

17.  Nail discolorations N     Y(3)
18.  Bumpy skin on back or arms N     Y(3)
19.  Wounds heal slowly N     Y(3)
20.  Hair is easily plucked out or falls out, grows slow N     Y(3)
21.  Lips are red and swollen N     Y(3)
22.  Tongue is red, swollen, raw looking N     Y(3)
23.  Impaired taste and smell N     Y(3)
24.  Neck, armpit groin swelling N     Y(5)
 
Total Points __________

Section C

1.  Muscles fatigue quickly 0 1 2 3
2.  Moody, irritable, tired 0 1 2 3
3.  Severe fatigue 0 1 2 3
4.  Severe joint pain, redness, swelling 0 1 2 3
5.  Chronic pain, stiffness througout body 0 1 2 3
6.  Migraine headaches 0 1 2 3
7.  Specific food(s) worsen pain, inflamation, stiffness 0 1 2 3
8.  Sensitive to light (skin or ees) 0 1 2 3
9.  Dark circles under eyes 0 1 2 3
10.  Swollen-looking face or body 0 1 2 3
11.  Localized or general itching - eyes, ears, throat, nose, skin 0 1 2 3
12.  Clear, wattery discharge from nose, eyes 0 1 2 3
13.  Extreme dryness of eyes, nasal passages, mouth 0 1 2 3
14.  Sneezing 0 1 2 3
15.  Cough or wheezing 0 1 2 3
16.  Moldy, damp environments trigger sickness 0 1 2 3
17.  Post nasal drip with certain foods 0 1 2 3
18.  Heart palpitations after eating certain foods 0 1 2 3
19.  Weight loss, muscle weakness N     Y(3)
20.  Scalp hair falls out easily in clumps N     Y(3)
21.  Hair loss, entire body N     Y(5)
22.  Easy bruising N     Y(3)
23.  Nails -loosened, pitted, discolored N     Y(3)
 
Total Points __________
 
PART IV

Section A

1.  Sense of being overly tired 0 1 2 3
2.  Prolonged recovery after exercise 0 1 2 3
3.  Coldness especially in hands and feet 0 1 2 3
4.  Difficulty breathing on exertion, palpitations 0 1 2 3
5.  Headache, dizziness, spots before eyes 0 1 2 3
6.  Irritable 0 1 2 3
7.  Forgetful, poor concentration 0 1 2 3
8.  Mild yellowing of eyes or skin 0 1 2 3
9.  Ringing in ears 0 1 2 3
10.  Susceptible to infections 0 1 2 3
11.  Jaundice and dark urine 0 1 2 3
12.  Black stool (no iron supplements) 0 1 2 3
13.  Unusual cravings for clay, dirt, ice 0 1 2 3
14.  Fingernails are flattened, spoon shaped, brittle, thin 0 1 2 3
15.  White patches on skin N     Y(5)
16.  Pale lips, gums, eyelids, nail beds N     Y(3)
17.  Red, sore tongue N     Y(3)
18.  Mouth, throat, rectum ulcers N     Y(3)
19.  Unusual bruising N     Y(3)
20.  Spontaneous bleeding - nose, mouth, gums, rectum or vagina N     Y(3)
21.  Small red dots under the skin N     Y(5)
22.  Sores in the corner of mouth N     Y(3)
23.  Smooth tongue N     Y(3)
 
Total Points __________

Section B

1.  Nosebleeds 0 1 2 3
2.  Headache, typically in morning 0 1 2 3
3.  Weakness, fatigue, nervous 0 1 2 3
4.  Ringing in ears 0 1 2 3
5.  Dizziness, drowsiness 0 1 2 3
6.  Blushing - no apparent cause 0 1 2 3
7.  Numbness, tingling in hands and feet 0 1 2 3
8.  Blurred vision 0 1 2 3
 
Total Points __________

Section C

1.  Feel jittery 0 1 2 3
2.  Heartburn that moves to neck, jaws, left shoulder and arm 0 1 2 3
3.  First effort of the day causes pain around chest 0 1 2 3
4.  Dizziness 0 1 2 3
5.  Choking, smothering sensation 0 1 2 3
6.  Exhaust with minor exertion 0 1 2 3

 

 

Section C (continued)

7.  Heart pounds easily 0 1 2 3
8.  Heavy sweating (no exertion) 0 1 2 3
9.  Mild or severe chest pain 0 1 2 3
10.  Difficulty catching breath especially during exercise 0 1 2 3
11.  Wheezing or dry cough 0 1 2 3
12.  Heart palpitations - slow, rapid or irregular 0 1 2 3
13.  Swelling in feet, ankle, legs comes and goes 0 1 2 3
14.  Veins on neck are prominent 0 1 2 3
 
Total Points __________

Section D

1.  Fluid retention 0 1 2 3
2.  Numbness, tingling, prickling sensation in hands, feet 0 1 2 3
3.  Muscle pain in the calves or thighs when walking 0 1 2 3
4.  Muscle pain at rest 0 1 2 3
5.  Cold feet 0 1 2 3
6.  Headaches 0 1 2 3
7.  Dizziness, everything spins 0 1 2 3
8.  Poor concentration 0 1 2 3
9.  Slurred speech 0 1 2 3
10.  Ringing in ears 0 1 2 3
11.  Brief moments of hearing loss 0 1 2 3
12.  Nausea comes and goes quickly 0 1 2 3
13.  Falling without known cause 0 1 2 3
14.  Brief difficulty swallowing 0 1 2 3
15.  Brief difficulty speaking 0 1 2 3
16.  Stammering or twitching of tongue 0 1 2 3
17.  Double vision 0 1 2 3
18.  Difficulty understanding spoken or written word 0 1 2 3
19.  Brief loss of muscular coordination 0 1 2 3
20.  Inability to recognize persons or things that pass very quickly 0 1 2 3
21.  Inability to feel pain or temperature usually on one side that disappears quickly 0 1 2 3
22.  One leg or arm - shiny hairless skin N     Y(5)
23.  Discolored or blue toes N     Y(5)
24.  Open sores on feet and legs N     Y(5)
25.  Fingers and toes numb in response to cold weather even when protected. N     Y(5)
 
Total Points __________
 
PART V

Section A

Missing meals or fasting is associated with the following:

1.  Sudden anxiety associated with hunger 0 1 2 3
2.  Tingling sensation in hands 0 1 2 3
3.  Palpitations 0 1 2 3
4.  Feel shaker, jittery, tremors 0 1 2 3
5.  Weakness 0 1 2 3
6.  Profuse perspiration, clammy skin 0 1 2 3
7.  Nightmares 0 1 2 3
8.  Awoke from sleep restless 0 1 2 3
9.  Agitated, easily upset, nervous 0 1 2 3
10.  Poor memory, forgetful 0 1 2 3
11.  Confusion, disoriented 0 1 2 3
12.  Dizziness, feel faint 0 1 2 3
13.  Feeling cold, numbness 0 1 2 3
14.  Mild headache 0 1 2 3
15.  Blurred or double vision 0 1 2 3
16.  Lack of coordination 0 1 2 3
 
Total Points __________

 

 

Section B

1.  Excessive, frequent urination 0 1 2 3
2.  Increased thirst and appetite 0 1 2 3
3.  Blurred vision, failing eyesight 0 1 2 3
4.  Fatigue, drowsiness 0 1 2 3
5.  Crave sweets, but eating sweets does not relieve craving 0 1 2 3
6.  Feel hungry for air (can't get enough) 0 1 2 3
7.  Breath smells sweet 0 1 2 3
8.  Depressed 0 1 2 3
9.  Tingling, numbness, prickling sensation in extremities 0 1 2 3
10.  Profuse sweating 0 1 2 3
11.  Dribble after voiding 0 1 2 3
12.  Impotency 0 1 2 3
13.  Dizziness when standing from sitting position 0 1 2 3
14.  Slurred speech 0 1 2 3
15.  Unintentional weight loss 0 1 2 3
16.  Reoccurring persistent infection bladder, skin, or gums 0 1 2 3
17.  Boils and leg sores 0 1 2 3
18.  Very slow wound healing 0 1 2 3
19.  Excessive weight gain 0 1 2 3
 
Total Points __________
PART VI
1.  Weakness and fatigue 0 1 2 3
2.  Chest discomfort, pain 0 1 2 3
3.  Sudden breathing difficulty 0 1 2 3
4.  Shortness of breath 0 1 2 3
5.  Shallow breathing 0 1 2 3
6.  Noisy rattling sounds when breathing in or out 0 1 2 3
7.  Cough - dry or moist 0 1 2 3
8.  Rapid heartbeats 0 1 2 3
9.  Excessive perspiration 0 1 2 3
10.  Anxiety, restlessness 0 1 2 3
11.  Consistent low-grade temperature (100-101°) 0 1 2 3
12.  Bluish nails and lips 0 1 2 3

 

 

13.  Post nasal drip 0 1 2 3
14.  Sputum - thick, clear, yellow 0 1 2 3
15.  Sputum - smells offensive 0 1 2 3
16.  Bloody sputum 0 1 2 3
17.  Bad breath 0 1 2 3
18.  Wheezing 0 1 2 3
19.  Loud snoring 0 1 2 3
20.  Sleepy during day 0 1 2 3
21.  Morning headache 0 1 2 3
22.  Difficulty concentrating 0 1 2 3
23.  Unexplained weight loss N     Y(3)
24.  Infections settle in lungs N     Y(3)
25.  Flu symptoms last longer than 5 days N     Y(3)
 
Total Points __________

PART VII
1.  Retain fluid throughout body 0 1 2 3
2.  Mild lower back pain 0 1 2 3
3.  Frequent urge to urinate, but only small amounts pass 0 1 2 3
4.  Interruption of urine stream 0 1 2 3
5.  Excessive urination 0 1 2 3
6.  Excessive urination at night 0 1 2 3
7.  Burning when urinating 0 1 2 3
8.  Frequent urination with urgency 0 1 2 3
9.  Rarely need to urinate 0 1 2 3
10.  Difficulty passing urine 0 1 2 3
11.  Dripping after urination 0 1 2 3

 

 

12.  Can't hold urine 0 1 2 3
13.  Bloody, cloudy and/or darkened urine 0 1 2 3
14.  Strong smelling urine 0 1 2 3
15.  Joint and muscle pain 0 1 2 3
16.  Tingling in joints 0 1 2 3
17.  Dark circles under eyes 0 1 2 3
18.  Gray, blackish caste to skin 0 1 2 3
19.  Back or leg pains associated with dripping after urination N     Y(5)
20.  Poor skin elasticity, dryness N     Y(3)
 
Total Points __________
 
PART VIII (Men Only)

Section A

1.  Frequent or urgent need to urinate 0 1 2 3
2.  Delayed, weak, or interrupted urinary stream 0 1 2 3
3.  Pain or burning upon urination 0 1 2 3
4.  Urge to urinate several times a night 0 1 2 3
5.  Rose colored (bloody) urine 0 1 2 3
6.  Difficulty urinating 0 1 2 3
7.  A sense of bladder fullness 0 1 2 3
8.  Ejaculation causes pain 0 1 2 3
9.  Blood in the semen 0 1 2 3
10.  Lack of sex drive 0 1 2 3
11.  Impotency 0 1 2 3
12.  Pain or fatigue in the legs or back 0 1 2 3
13.  Dripping after urination 0 1 2 3
14.  Increased straining with small amounts of urine passed 0 1 2 3
15.  Anemia N     Y(3)
 
Total Points __________

 

 

Section B

1.  Itchy patches around inner thigh and groin 0 1 2 3
2.  Itching at night 0 1 2 3
3.  Painful testicles 0 1 2 3
4.  Difficulty attaining and/or maintaining an erection 0 1 2 3
5.  Low sexual drive 0 1 2 3
6.  Premature ejaculation 0 1 2 3
7.  Low energy level or stamina 0 1 2 3
8.  Inflammation of the head of penis N     Y(5)
9.  Genital and/or rectal rash or irritation N     Y(5)
10.  Distorted nail growth N     Y(3)
11.  Loss of pubic or armpit hair N     Y(3)
12.  Infertile N     Y(3)
13.  Low sperm count, low sperm motility N     Y(3)
14.  Unexplained weight gain N     Y(3)
15.  Testicles appear smaller N     Y(3)
16.  Development of breasts or nipple tenderness N     Y(3)
17.  Feeling of heaviness or hardness in testicle N     Y(3)
18.  Sparse beard or slow hair growth N     Y(3)
19.  Decreased body hair N     Y(3)
20.  Fine wrinkling in corner of mouth or around eyes N     Y(3)
 
Total Points __________
 
PART IX (Women Only)

Section A

1.  Insomnia 0 1 2 3
2.  Abdominal bloating 0 1 2 3
3.  Breast tenderness, swelling 0 1 2 3
4.  Breast lumps appear 0 1 2 3
5.  Heart palpitations 0 1 2 3
6.  Sweating and flushing 0 1 2 3
7.  Depressed, irritable, nervous 0 1 2 3
8.  Easy to anger, resentful 0 1 2 3
9.  Easily overwhelmed 0 1 2 3
10.  Nausea and/or vomiting 0 1 2 3
11.  Diarrhea or constipation 0 1 2 3
12.  Headache 0 1 2 3
13.  Food cravings, binge eating 0 1 2 3
14.  Back pain 0 1 2 3
15.  Numbness, tingling in hands and feet 0 1 2 3
16.  Clumsiness 0 1 2 3
17.  Feeling hopeless, sad 0 1 2 3
18.  Weight gain, water N     Y(3)
19.  Suicidal N     Y(10)
 
Total Points __________

Section B

1.  Vaginal dryness, pain 0 1 2 3
2.  Painful intercourse 0 1 2 3
3.  Engorged breasts 0 1 2 3
4.  Milk production (not nursing) 0 1 2 3
5.  Disinterest in sex 0 1 2 3
6.  Blurred vision 0 1 2 3
7.  Headache 0 1 2 3
8.  Acne and/or oily skin 0 1 2 3
9.  Aggressive feelings 0 1 2 3
10.  Overwhelming urges for sexual intercourse 0 1 2 3
11.  Absence of menstrual flow for six or more months N     Y(20)
12.  Occasionally skip periods N     Y(5)
13.  Menstruation began after 16 years of age N     Y(3)
14.  Breasts shrinking N     Y(5)
15.  Thinning pubic and armpit hair N     Y(5)
16.  Unable to get pregnant N     Y(10)
17.  Miscarriage N     Y(3)
18.  Excess facial hair N     Y(5)
19.  Poor sense of smell N     Y(3)
20.  Monthly abdominal pain without bleeding N     Y(5)
 
Total Points __________

Section C

1.  Painful intercourse 0 1 2 3
2.  Menstrual type pain between menses 0 1 2 3
3.  Irregular time intervals between periods N     Y(5)
4.  Extended menses greater than 32 days N     Y(10)
5.  Shortened menses (less than every 24 days) N     Y(5)
6.  Vaginal bleeding between periods N     Y(10)
7.  Vaginal discharge between periods N     Y(5)
8.  Pain during periods is getting progressively worse N     Y(5)

 

 

Section C (continued)

9.  Pain, cramps 0 1 2 3
10.  Unusual fatigue, can't work 0 1 2 3
11.  Irritable and depressed 0 1 2 3
12.  Constipation and/or diarrhea 0 1 2 3
13.  Lower abdominal pain, bloating 0 1 2 3
14.  Nausea and/or vomiting 0 1 2 3
15.  Lower backache 0 1 2 3
16.  Pelvic and/or rectal pressure 0 1 2 3
17.  Urinary difficulties 0 1 2 3
18.  Frequent urination N     Y(5)
19.  Scanty blood flow N     Y(3)
20.  Heavy blood flow N     Y(3)
 
Total Points __________

Section D

1.  Lumps are painful, tender 0 1 2 3
2.  Clear, gray or yellow vaginal discharge 0 1 2 3
3.  Vaginal bleeding after sex or between periods 0 1 2 3
4.  Burning or itching of the external genitalia 0 1 2 3
5.  Urgent, painful urination 0 1 2 3
6.  Lower abdominal or back pain 0 1 2 3
7.  Heavy, watery and bloody vaginal discharge 0 1 2 3
8.  Heavy menstrual flow 0 1 2 3
9.  Pelvic cramps 0 1 2 3
10.  Thin, scant white vaginal discharge 0 1 2 3
11.  Greenish, yellow, or offensive discharge 0 1 2 3
12.  Cheesy white discharge 0 1 2 3
13.  Breast lumps or swelling N     Y(10)
14.  Lumps hurt just before period N     Y(5)
15.  Swelling under armpit N     Y(5)
16.  Change in breast size, shape N     Y(10)
17.  White or slightly bloody vaginal discharge, one week prior to period N     Y(10)
 
Total Points __________

Section E

1.  Insomnia 0 1 2 3
2.  Abdominal bloating 0 1 2 3
3.  Breast tenderness, swelling 0 1 2 3
4.  Breast lumps appear 0 1 2 3
5.  Heart palpitations 0 1 2 3
6.  Sweating and flushing 0 1 2 3
7.  Depressed, irritable, nervous 0 1 2 3
8.  Easy to anger, resentful 0 1 2 3
9.  Easily overwhelmed 0 1 2 3
10.  Nausea and/or vomiting 0 1 2 3
11.  Diarrhea or constipation 0 1 2 3
12.  Headache 0 1 2 3
13.  Food cravings, binge eating 0 1 2 3
14.  Back pain 0 1 2 3
15.  Numbness, tingling in hands and feet 0 1 2 3
16.  Clumsiness 0 1 2 3
17.  Feeling hopeless, sad 0 1 2 3
18.  Weight gain, water N     Y(3)
19.  Suicidal N     Y(10)
 
Total Points __________
 
PART X

Section A

1.  Generalized bone tenderness and achiness 0 1 2 3
2.  Localized bone pain 0 1 2 3
3.  Bone deformity or swelling 0 1 2 3
4.  Shins hurt during or after exercise 0 1 2 3
5.  Low back or hip pain 0 1 2 3
6.  Difficulty sitting straight 0 1 2 3
7.  Limp, walking difficulties 0 1 2 3
8.  Crunching or cracking sounds when moving joints 0 1 2 3
9.  Hands, feet, throat spasms or feel numb 0 1 2 3
10.  Joint pain and stiffness - especially spine, hips, knees 0 1 2 3
11.  Hearing loss, headaches, ringing in ears 0 1 2 3
12.  Cavities N     Y(5)
13.  Tooth loss due to gum disease N     Y(5)
14.  Established bone loss N     Y(10)
15.  Calcium deposits N     Y(5)
16.  Spinal curvature N     Y(10)
17.  Recent loss of height N     Y(10)
18.  Bow legs N     Y(5)
19.  Stooped posture N     Y(5)
20.  Hump at base of neck N     Y(5)
21.  Irregular patches of increased pigmentation N     Y(3)
22.  Unexplained bone fracture N     Y(10)
 
Total Points __________

Section B

1.  Muscle aches and pains 0 1 2 3
2.  Muscle stiffness, tension 0 1 2 3
3.  Specific points on body feel sore when presses 0 1 2 3
4.  Headaches 0 1 2 3
5.  Fatigue, tired, sluggish 0 1 2 3
6.  Difficulty sleeping 0 1 2 3
7.  Feel unrefreshed upon awakening 0 1 2 3
8.  Difficulty speaking, swallowing 0 1 2 3
9.  Muscles cramp or spasm 0 1 2 3
10.  Muscles twitch or tremble - eyelids, thumb, calf muscle 0 1 2 3
11.  Irresistible urge to move legs 0 1 2 3
12.  Legs move during sleep 0 1 2 3
13.  Unpleasant crawling sensation inside calves, while lying down 0 1 2 3
14.  Numbing, tingling sensation 0 1 2 3
15.  Excessive joint mobility 0 1 2 3
16.  Unable to fully straighten or extend legs and/or arms 0 1 2 3
17.  Upper or lower back pain 0 1 2 3
18.  Loss of muscle strength N     Y(3)
19.  Muscle loss, wasting N     Y(3)
 
Total Points __________

Section C

1.  Joint stiffness, soreness, swelling 0 1 2 3
2.  Red, swollen painful joints 0 1 2 3
3.  Joint stiffness improves when resting, worsens with movement 0 1 2 3
4.  Dry mouth 0 1 2 3
5.  Dry painful eyes 0 1 2 3
6.  Joint stiffness worsens with rest, improves with movement 0 1 2 3
7.  Cracking joints 0 1 2 3
8.  Limp 0 1 2 3
9.  Shooting, aching, tingling pain down the back of leg 0 1 2 3

 

 

Section C (continued)

10.  Joint pain involves one or a few joints 0 1 2 3
11.  Joints hurt when moving or carrying weight 0 1 2 3
12.  Limited range of motion 0 1 2 3
13.  Difficulty standing up from sitting position 0 1 2 3
14.  Walks slowly 0 1 2 3
15.  Headache 0 1 2 3
16.  Difficulty chewing food or opening mouth 0 1 2 3
17.  Intermittent pain, ache on one side of head spreading to cheek, temple, lower jaw, ear neck and shoulder 0 1 2 3
18.  Numbness, prickling, tingling sensation in the neck, shoulder and arms 0 1 2 3
19.  Injure, strain, sprain easily 0 1 2 3
20.  Discomfort or pain in neck, shoulder or arm 0 1 2 3
21.  Involuntary muscle spasms 0 1 2 3
22.  Deliberate movement with hands are difficult 0 1 2 3
23.  Red painless skin lumps on elbows, knees, toes, ear, nose, back of scalp N     Y(5)
24.  Knobby overgrowths on the joints closest to the fingertips N     Y(5)
25.  Muscle loss around inflamed joint N     Y(10)
26.  Double jointed N     Y(3)
27.  One leg shorter than the other N     Y(5)
 
Total Points __________

Section D Neurological

1.  Head feels heavy 0 1 2 3
2.  Light headedness/fainting 0 1 2 3
3.  Ringing/buzzing in ears 0 1 2 3
4.  Trembling hands 0 1 2 3
5.  Limbs feel too heavy to hold up 0 1 2 3
6.  Loss of feeling in hands and/or feet (toes) 0 1 2 3
7.  Tingling sensation followed by numbness, or pain begins in hands and feet and spreads toward the center of your body 0 1 2 3
8.  Unsteady gait, lose balance 0 1 2 3
9.  Muscles feel weak 0 1 2 3
10.  Weak grip with spasm and arm weakness 0 1 2 3
11.  Exhaustion on slightest effort 0 1 2 3
12.  Need for 10-12 hours sleep 0 1 2 3
13.  Muscular weakness begins in leg and moves upward 0 1 2 3
14.  Difficulty walking, moving around, handling small objects 0 1 2 3
15.  Nervous, anxious 0 1 2 3
16.  Convulsions 0 1 2 3
17.  Confused, forgetful 0 1 2 3
18.  Slowed or slurred speech 0 1 2 3
19.  Difficulty breathing 0 1 2 3
20.  Blurred vision 0 1 2 3
21.  Eyelids droop 0 1 2 3
22.  Impaired hearing, eyesight, sense of touch smell taste N     Y(10)
23.  Accident prone - trip, stumble, feel clumsy N     Y(5)
 
Total Points __________
 
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WHICH OF THE FOLLOWING MEDICATIONS ARE YOU TAKING

[  ] Antacids [  ] Cortisone/anti-inflammatory [  ] Oral contraceptives
[  ] Antibiotic/antifungal [  ] Heart medication [  ] Radiation
[  ] Antidepressants [  ] High blood pressure [  ] Relaxant/sleeping pills
[  ] Anti-diabetic/insulin [  ] Hormones [  ] Thyroid medication
[  ] Asprin / Tylenol [  ] Laxatives [  ] Ulcer medication
[  ] Chemotherapy [  ] Lithium    

Other: _______________________________________________________________

Recreational drugs: _____________________________________________________


WHICH OF THE FOLLOWING DO YOU EAT, DRINK, OR USE

[  ] Alcohol [  ] Cigarettes [  ] Fried foods
[  ] Candy [  ] Coffee [  ] Luncheon meats
[  ] Carbonated beverages [  ] Distilled water [  ] Margarine
[  ] Chew tobacco [  ] Fast food restaurants [  ] Saccharine (Sweet & Low)

Vitamins/minerals (please list): _________________________________________

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WHICH OF THE FOLLOWING APPLY TO YOU

[  ] Are under excessive stress [  ] Do not exercise regularly
[  ] Salt food without tasting [  ] Are exposed to chemicals at work
[  ] Are exposed to cigarette smoke [  ] Diet often


LIST YOUR "TOP" HEALTH SYMPTOM COMPLAINTS:

1. _________________________________________________________________

2. _________________________________________________________________

3. _________________________________________________________________

4. _________________________________________________________________

5. _________________________________________________________________

 

DO YOU HAVE ANY OTHER SYMPTOMS NOT COVERED IN THIS QUESTIONNAIRE?

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