Confidential
Health Appraisal Questionnaire

Antacids       Insulin     Cortisone/Anti-inflammatories     Blood Pressure     Laxatives

Relaxants/Sleeping Pills     Antibiotics/Antifungal     Aspirin     Lithium     Recreational Drugs

Thyroid Medications     Antidepressants     Chemotherapy     Heart Medications     Hormones

Oral Contraceptives (please specify) ....................................................................

Ulcer Medications (please specify) ....................................................................

Alcohol    Coffee     Deli Meats     Refined Sugars     Distilled Water     Cigarettes     Fried Foods

Vitamins and minerals (please specify) ....................................................................

Diet often     Salt food without tasting     Are exposed to chemicals at work    

Are under excessive stress    Do not exercise regularly     Are exposed to cigarette smoke

Instructions:   Circle the number that best describes the intensity of your symptoms (3 = most severe) If you do not know the answer to a question, please leave it blank.

Burping	0 1 2 3	Stomach pains	0 1 2 3
Fullness for extended time after meal	0 1 2 3	Dependency on antacids	0 1 2 3
Bloating	0 1 2 3	Stomach upsets easily	0 1 2 3
Poor appetite	0 1 2 3	Difficulty belching	0 1 2 3
History of constipation	0 1 2 3	Stomach pain when emotionally upset	0 1 2 3
Known food allergies	0 1 2 3	Sudden acute indigestion	Yes   /   No
Abdominal cramps	0 1 2 3	Fatigue after eating	0   1   2   3
Lower bowel gas	0 1 2 3	Alternating constipation and diarrhoea	0 1 2 3
Diarrhoea	0 1 2 3	Frequent and recurrent infections (colds)	0 1 2 3
Bladder and kidney infections	0 1 2 3	Vaginal yeast infections (thrush)	0 1 2 3
Stool poorly formed	0 1 2 3	Foul smelling stool	0 1 2 3
Light coloured stool	0 1 2 3	Intolerance to greasy food	0 1 2 3
Pain in right side under rib cage	0 1 2 3	Have had jaundice or hepatitis	Y  /  N
Retain water	0 1 2 3	Bad breath	0 1 2 3
Strong smelling urine	0 1 2 3	Dry skin	0 1 2 3
Sensitive to the cold	0 1 2 3	Sugar causes irritability and mood swings	0 1 2 3
Cold hands and feet	0 1 2 3	Sensitivity to exhaust fumes	0 1 2 3
Eczema and psoriasis	Y  /  N	Asthma/bronchitis	Y  /  N
Migraine headaches	Y  /  N	Entire body aches, painful to touch	0 1 2 3
History of gastritis or ulcers	Y  /  N	Abdominal cramps	0 1 2 3
Current ulcer	Y  /  N	Black stool when not taking iron supplements	Y  /  N
Roughage & fibre causes infections	Y  /  N	Mucous in stool	0 1 2 3
Toe and fingernail infection	0 1 2 3	History of antibiotic use	0 1 2 3
Nausea on waking	0 1 2 3	Painful to pass stool	0 1 2 3
Headaches after eating	0 1 2 3	Red blood in stool	Y  /  N
Body odour	0 1 2 3	High blood cholesterol	0 1 2 3
Low blood cholesterol	0 1 2 3	HDL cholesterol	0 1 2 3
Low sex drive	0 1 2 3	Puffy, wrinkly skin	0 1 2 3
Lack of mental alertness	0 1 2 3	Cannot tolerate much exercise	0 1 2 3
Depression or rapid mood swing	0 1 2 3	Dark circles under the eyes	0 1 2 3
Dizziness upon standing	0 1 2 3	Swollen joints	0 1 2 3
Food sensitivity	0 1 2 3	Eyes sensitive to bright lights	0 1 2 3
Chronic pain	0 1 2 3	Painful stomach &/ or intestine	0 1 2 3
Mucous in throat	0 1 2 3	Post nasal drip	0 1 2 3
Ear discharge or ears blocked up	0 1 2 3	Eyes itch	0 1 2 3
Loss of smell	0 1 2 3	Sinusitis/rhinitis	0 1 2 3
Breathe through mouth	0 1 2 3	Swollen or painful tongue	0 1 2 3
Bedwetting	0 1 2 3	Hyperactivity	0 1 2 3
Chronic lung congestion	0 1 2 3	Bumpy skin on backs of arms	0 1 2 3
Shortness of breath	0 1 2 3	Chest pain while walking	0 1 2 3
Heaviness in legs	0 1 2 3	Numbness in extremities	0 1 2 3
Poor concentration	0 1 2 3	Heart misses beats or has extra beats	0 1 2 3
Swelling of feet and ankles	0 1 2 3	Calmer after eating	0 1 2 3
Heartburn after eating	0 1 2 3	Dizziness	0 1 2 3
Is your blood pressure high?	0 1 2 3	Vertigo	0 1 2 3
Is your blood pressure high?	Y  /  N	Dizziness when standing suddenly	0 1 2 3
Loss of vision when standing suddenly	0 1 2 3	Headaches relieved by eating sweets/alcohol	0 1 2 3
Crave sweets	0 1 2 3	Irritable if a meal is missed	0 1 2 3
Feel shaky	0 1 2 3	Feel tired or weak if a meal is missed	0 1 2 3
Failing eyesight	0 1 2 3	Heart palpitations after eating sweets	0 1 2 3
Chest pain	0 1 2 3	Family history of diabetes	0 1 2 3
Sensitive to smog	0 1 2 3	Work around people who smoke	0 1 2 3
Coughing up blood	0 1 2 3	Coughing up phlegm	0 1 2 3
Smoker?	Y  /  N	No. Per Day	.................
Frequent urination	0 1 2 3	Frequent bladder infections	0 1 2 3
Rarely need to urinate	0 1 2 3	Urination when you cough or sneeze	0 1 2 3
Painful burning when passing urine	0 1 2 3	Dripping after urination	0 1 2 3
Pain in arm/hands	0 1 2 3	Have used antibiotics to control urinary tract infections	Y  /  N
Arthritis	0 1 2 3	Gum disease	0 1 2 3
Bone loss	Y  /  N	Catch colds easily when weather changes	0 1 2 3
Certain foods make you sick, jittery, depressed	0 1 2 3	Inflamed or bleeding gums	0 1 2 3
Running noses	0 1 2 3	Boils or styes	0 1 2 3
Throat infections	0 1 2 3	Nose bleeds	0 1 2 3
Loss of taste	0 1 2 3	Poor wound healing	0 1 2 3
Cold sores, fever blisters	0 1 2 3	Swollen Lymph glands	0 1 2 3
Hair loss	0 1 2 3	Ear infection	0 1 2 3
Slow to recover from cold or flu	0 1 2 3	Poor concentration	0 1 2 3
Calf muscles cramp while walking	0 1 2 3	Headaches	0 1 2 3
Heart pounds easily	0 1 2 3	Rapid beating heart	0 1 2 3
Ringing in ears	0 1 2 3	Pain in the morning in the back of the head and neck	0 1 2 3
Exhaust with minor exertion	0 1 2 3	Do you do aerobic exercise?	Y  /  N
Do you exercise regularly?	Y  /  N	Night sweats	0 1 2 3
Feel tired 1 - 3 hours after eating?	Y  /  N	Increased thirst	0 1 2 3
Lowered resistance to infection	0 1 2 3	Fatigue	0 1 2 3
Overweight	0 1 2 3	Feel 'picked up' from exercise	0 1 2 3
Wake up in the middle of the night craving sweets	0 1 2 3	Need to drink coffee to get started	0 1 2 3
Impatient, moody, nervous	0 1 2 3	Difficulty breathing	0 1 2 3
Chronic cough	0 1 2 3	Infection settles in lungs	0 1 2 3
Bronchitis	0 1 2 3	Exposed to chemicals & radiation	Y  /  N
Pain around ribs	0 1 2 3	Rose coloured (bloody) urine	0 1 2 3
Can't hold urine	0 1 2 3	Strong smelling urine	0 1 2 3
Cloudy urine	0 1 2 3	History of bladder infections	0 1 2 3
Difficulty passing urine	0 1 2 3	Leg cramps at night	0 1 2 3
Stiff all over	0 1 2 3	Stiff in morning	0 1 2 3
Unable to sit straight	0 1 2 3	Told you have Osteoporosis/Osteomalacia	Y  /  N
Use antacids?	Y  /  N	If yes, number per week	....................
Swollen knees/elbows	0 1 2 3	Tight muscle spasms	0 1 2 3
Injure easily	0 1 2 3	Tightness in shoulder muscles	0 1 2 3
Can't fall asleep	0 1 2 3	Nightmares	0 1 2 3
Leg cramps/restless legs at night	0 1 2 3	Intense dreams	0 1 2 3
Pain in neck &/or shoulders	0 1 2 3	Sleep walk	0 1 2 3
Recent bone fracture	Y  /  N	Post menopausal	Y  /  N
Athletic injury	0 1 2 3	Tendonitis	0 1 2 3
Joint pain	0 1 2 3	Muscle cramps	0 1 2 3
Awake frequently through night	0 1 2 3	Restless, uneasy sleeper	0 1 2 3
Wake up in middle night and can't get back to sleep	0 1 2 3

This section males only

Difficulty urinating	0 1 2 3	A sense of bladder fullness	0 1 2 3
Increased straining with smaller & smaller amounts of urine passed	0 1 2 3	Rose-coloured (bloody) urine	0 1 2 3
Pain or burning when urinating	0 1 2 3	Wake up to urinate at night	Y/N
Dripping after urination	0 1 2 3	Discharge from penis	0 1 2 3
Past or present rash on penis	0 1 2 3	Swollen genitals	0 1 2 3
Difficulty attaining &/or maintaining an erection	0 1 2 3	Have an STD now?	Y  /  N
Have had an STD in the past	Y  /  N	Anxiety or fear of sexual intimacy with women	0 1 2 3
Premature ejaculation	0 1 2 3	Pain/coldness in genital area	0 1 2 3
Varicose veins on scrotum	0 1 2 3	Low sperm count	0 1 2 3
Infertile	0 1 2 3	Pain or fatigue in the legs or back	0 1 2 3
Lack of sex drive	0 1 2 3	Ejaculation causes pain	0 1 2 3
Swelling in groin	0 1 2 3

This section females only

Monthly weight gain	0 1 2 3	Moodiness/irritability	0 1 2 3
Pain during period is getting progressively worse with time	0 1 2 3	Leg cramps & tenderness	0 1 2 3
Breasts are sore to touch	0 1 2 3	Ovaraian cysts	Y  /  N
Pain in the ovaries	0 1 2 3	Uterine cysts	Y  /  N
Low backache	0 1 2 3	Breasts are sore to touch	0 1 2 3
Pre-menstrual breast pain or discomfort	0 1 2 3		0 1 2 3
Mother used DES (hormones) in pregnancy	Y  /  N	Low or no desire for sex	0 1 2 3
Dislike for intercourse	0 1 2 3	Missed periods	0 1 2 3
Form of birth control............................	0 1 2 3	Night sweats	0 1 2 3
Hysterectomy	Y  /  N	Heavy bleeding	0 1 2 3
Dryness of skin, hair and vagina	0 1 2 3	Pain & cramps without blood flow	0 1 2 3
Insomnia	0 1 2 3	Depression	0 1 2 3
Bloating & swelling	0 1 2 3	Nausea &/or vomiting	0 1 2 3
Vaginal bumps & sores	0 1 2 3	Pubic area sore	0 1 2 3
Headaches	0 1 2 3	Easily distracted	0 1 2 3
Breast lumps	Y  /  N	Water retention	0 1 2 3
Anger	0 1 2 3	Vaginal itching	0 1 2 3
Vaginal discharge	0 1 2 3	Recent pap smear positive	0 1 2 3
Light scanty blood flow	0 1 2 3	Unable to fall pregnant	0 1 2 3
Family history of breast cancer	0 1 2 3	Hot flushes	0 1 2 3
Miscarriages	Y  /  N How many?...........	Craving for sweets	0 1 2 3
Dull ache radiating to low back or legs	0 1 2 3	Menstrual pain	0 1 2 3

Do you have any other symptoms that have not been covered by this questionnaire?
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