Health Appraisal Questionnaire

Health Appraisal Questionnaire
Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DIRECTIONS:
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental, and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity, and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

Rows	No	Yes
Digestive problems that subside with rest and relaxation

Rows	No	Yes
Stopped menstruating around six months ago, yet still experience some vaginal bleeding

Please mark an "X" to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or texture (e.g., moles, ashes, etc.
Describe what you feel or observe in your own words.

Results

Rows	Scores
Gastric Function
Gl Inflammation
Small intestine & Pancreas
Colon
Hepatobiliary Function
Thyroid
Adrenal
Dysglycemia-L
Dysglycemia-E
Heart
Circulation
Depression
Anxiety
Anger
Eyes, Ears, Nose, Throat & Lungs
Kidney & Bladder
Bone Integrity
Connective Tissue
Muscle & Nerves
Central Nervous System
Cognition
Prostate Health
Premenstrual Balance
Menstruation
Reproductive Tissue Inflammation
Hormone Balance
Ovarian Function
Estrogen/ Progesterone Decline

Should be Empty:

Rows	No/ Rarely	Occasionally	Often	Frequently
Indigestion, food repeats on you after you eat
Excessive burping, belching and/or bloating following meals
Stomach spasms and cramping during or after eating
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
Bad taste in your mouth
Small amounts of food fill you up immediately
Skip meals or eat erratically because you have no appetite

Rows	No/ Rarely	Occasionally	Often	Frequently
Strong emotions or the thought or smell of food aggravates your stomach or makes it hurt
Feel hungry an hour or two after eating a good-sized meal
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
Burning sensation in the lower part of your chest, especially when lying down or bending forward
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
Feel a sense of nausea when you eat
Difficulty or pain when swallowing food or beverage

Rows	No/ Rarely	Occasionally	Often	Frequently
When massaging under your rib cage on your let side the part tenderness or soreness
Indigestion or fullness or tension in your abdomen is delayed, occurring 24 hours after eating a meal
Lower abdominal discomfort relieve with passage of gas or bowel movement
Specific foods/beverages aggravate indigestion
The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
Stool odor is embarrassing
Undigested food in your stool
Three or more large bowel movements daily
Diarrhea (frequent loose, watery stool)
Bowel movement shortly after eating (within 1 hour)

Rows	No/ Rarely	Occasionally	Often	Frequently
Discomfort, pain or cramps in your colon (lower abdominal area)
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
Generally constipated (or straining during bowel movements)
Stool is small, hard and dry
Pass mucus in your stool
Alternate between constipation and diarrhea 7 Rectal pain, itching or cramping

Rows	No/ Rarely	Occasionally	Often	Frequently
When massaging under your rib cage on your right side, there is pain, tenderness or soreness
Abdominal pain worsens with deep breathing
Pain at night that may move to your back or right shoulder
Bitter fluid repeats after eating
Feel abdominal discomfort or nausea when eating rich, fatty or fried foods
Throbbing temples and/or dull pain in forehead associated with overeating
Unexplained itchy skin that's worse at night
Stool color alternates from clay-colored to normal brown
General feeling of poor health
Aching muscles not due to exercise
Retain fluid and feel swollen around the abdominal area
Reddened skin, especially palms
Very strong body odor
Are you embarrassed by your breath?

Health Appraisal Questionnaire

PART 1

PART 2

PART 3

PART 4

PART 5

PART 6

PART 7

PART 8

PART 9

PART 10

PART 11

PART 12

(Menopausal women should skip to Sections E and F)

Rows	No	Yes
No urge to have a bowel movement
An almost continual need to have a bowel movement

Rows	No/ Rarely	Occasionally	Often	Frequently
Feel cold or chilled — hands, feet or all overfor no apparent reason
Your upper eyelids look swollen
Muscles are weak, cramp and/or tremble
Are you forgetful?
Do you feel like your heart beats slowly
Reaction time seems slowed down
In general, are you disinterested in sex because your desire is low?
Feel slow-moving, sluggish
Constipation

Rows	No	Yes
Dryness, discoloration of skin and/or hair
Have you noticed recently that your voice is deepening?
Thick, brittle nails
Weight gain for no apparent reason
Outer third of your eyebrow is thinning or disappearing
Swelling of the neck

Rows	No/ Rarely	Occasionally	Often	Frequently
Lingering mild fatigue after exertion or stress
Do you find that you get tired and exhaust easily?
Craving for salty foods
Sensitive to minor changes in weather and surrounding
Dizzy when rising or standing up from a kneeling position
Do bluish or black circles under your eyes
Have bouts of nausea with or without vomiting
Your body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful
Feel puffy and swollen all over your body

Rows	No	Yes
Catch colds or infections easily
Wounds heal slowly
Skin is gradually tanning without exposure to sun or the ingestion of high levels of carotene-rich foods (eg, daily carrot juice intake or supplements

Rows	No/ Rarely	Occasionally	Often	Frequently
A sense of weakness
A sudden sense of anxiety when you get hungry
Tingling sensation in your hands
A sensation of your heart beating too quickly or forcefully
Shaky, jittery, hands trembling
Sudden profuse sweating and/or your skin feels clammy
Nightmares possibly associated with going to bed on an empty stomach
Wake up at night feeling restless
Agitation, easily upset, nervous
Poor memory, forgetful
Confused or disoriented
Dizzy, faint
Cold or numb
Mild headaches or head pounding
Blurred vision or double vision
Feel clumsy and uncoordinated

Rows	No/ Rarely	Occasionally	Often	Frequently
Frequent urination during the day and night
Unusual thirst — feeling like you can't drink enough water
Unusual hunger — eating all the time
Vision blurs
Feel itchy all over
Tingling or numbness in your feet
Sense of drowsiness, lethargy during the day not associated with missing meals or not sleeping

Rows	No	Yes
Eating starchy foods, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight
Sores heal slowly
Loss of hair on your legs

Rows	No/ Rarely	Occasionally	Often	Frequently
Feel jittery
First effort of the day causes pain, pressure, tightness or heaviness around the chest
Exhaustion with minor exertion
Heavy sweating (no exertion, no hot flashes)
Difficulty catching breath, especially during exercise
Heart pounding, sensation of heart beating too quickly, too slowly or irregularly
Swelling in feet, ankles and/or legs comes and goes for no apparent reason

Rows	No/ Rarely	Occasionally	Often	Frequently
Muscle pain at rest
Cramp-like pains in your ankles, calves or legs
Numbness, tingling and prickling sensation in hands and feet
Cold feet and/or toes appear blue
Brief moments of hearing loss
Nausea comes and goes quickly (unrelated to eating)
Feel worse standing: legs get heavy and fatigued
Leg discomfort or fatigue relieved by elevating legs
Fingers and toes get numb in cold weather even when protected

Rows	No	Yes
Notice changes in your ability to feel pain or differentiate between sensations of hot or cold
Body hair on arms, hands, fingers, legs and toes) is thinning or has disappeared
Do you notice a decline in your ability to make decisions, concentrate, focus attention, or follow directions

Rows	No/ Rarely	Occasionally	Often	Frequently
Family, friends, work, hobbies, or activities you hold dear are no longer of interest
Do you cry?
Does life look entirely hopeless
Would you describe yourself as feeling miserable and sad, unhappy or blue
Do you find it hard to make the best of difficult situations
Sleep problems — too much or too little sleep

Rows	No	Yes
Changes in your appetite and weight
Lately you've noticed an inability to think clearly or concentrate
Difficulty making decisions and/or clarifying and achieving your goals

Rows	No/ Rarely	Occasionally	Often	Frequently
Do you feel pent up and ready to explode?
Are you prone to noisy and emotional outbursts?
Do you do things on impulse?
Are you easily upset or irritated?
Do you go to pieces if you don't control yourself ?
Do little annoyonces get on your nerves and make you angry?
Does it make you angry to have anyone tell you what to do?
Do you flare up in anger if you can't have what you want right away?

Rows	No/ Rarely	Occasionally	Often	Frequently
Does worrying get you down?
Does every little thing get on your nerves and wear you out
Would you consider yourself a nervous person
Do you feel easily agitated?
Do you shake and tremble
Are you keyed up and jittery
Do you tremble or feel weak when someone shouts at you
Do you become scared at sudden movements or noises at night
Do you find yourself sighing a lot?
Are you awakened out of your sleep by frightening dreams
Do frightening thoughts keep coming back in your mind
Do you become suddenly scared for no reason
Do you break out in a cold sweat?
"Butterflies in your stomach," nausea and/or diarrhea

Rows	No/ Rarely	Occasionally	Often	Frequently
Eyes water or tear
Mucus discharge from the eyes
Ears ache, itch, feel congested or sore
Discharge from ears
Is your nose continually congested
Does your nose run
Hoarse voice
Do you have to clear your throat?
Do you feel a choking lump in your throat?
Chest discomfort or pain
Do you experience sudden breathing difficulties?
Do you struggle with shortness of breath
Difficulty exhaling (breathing out)
Breathlessness followed by coughing during exertion, no matter how slight
Inability to breathe comfortably while lying down
Do you cough up lots of phlegm?
Can you hear noisy rattling sounds when breathing in and out
Are you troubled with coughing
Do you wheeze?
Do you have severe soaking sweats at night?
Do your lips and/or nails have a bluish hue?
Are you sleepy during the day?
Do you have difficulty concentrating

Rows	No	Yes
Are you prone to loud snoring
Nosebleeds
Do you suffer from severe colds
Do frequent colds keep you miserable all winter
Flu symptoms last longer than 5 days
Do infections settle in your lungs?
Eyes, ears, nose, throat, and lung symptoms seem associated with specific foods like dairy or wheat products
Eyes, ears, nose, throat, and lung symptoms are associated with seasonal changes

Rows	No/ Rarely	Occasionally	Often	Frequently
Involuntary loss of urine when you cough, lift something or strain during an activity
Mild lower back ache or pain
Abdominal achiness or pain
Pain or burning when urinating
Rarely feel the urge to urinate
Feel the need to urinate less than every two hours during the day or night
Strong smelling urine
Back or leg pains are associated with dripping after urination
Sore or painful genitals
Urine is a rose color
Sudden urge to void causes involuntary loss of urine
Generalized sense of water retention throughout your body

Rows	No/ Rarely	Occasionally	Often	Frequently
Bones throughout your entire body ache, feel tender or sore
Localized bone pain
Hands, feet or throat get tight, spasm or feel numb
Difficulty sitting straight
Upper back pain
Lower back pain
Pain when sitting down or walking
Find yourself limping or favoring one leg
Shins hurt during or after exercise

Rows	No/ Rarely	Occasionally	Often	Frequently
Are you stiff in the morning when you wake up
Difficulty bending down and picking up clothing or anything from the floor
Joint swelling, pain, or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)
Joints hurt when moving or when carrying weight
A routine exercise program, like daily walking, causes your knees to swell or hurt
Difficulty opening jars that were previously easy to open
Discomfort, numbness, prickling or tingling sensation, or pain in the neck, shoulder, or arm
Intermittent pain or ache on one side of head spreading to cheek, temple, lower jaw, ear, neck and shoulder
Difficulty chewing food or opening mouth
Difficulty standing up from a sitting position
Shooting, aching, tingling pain down the back of leg

Rows	No	Yes
Is it difficult to reach up and get a 5-pound object like a bag of flour from just above your head?
Injure, strain or sprain easily

Rows	No/ Rarely	Occasionally	Often	Frequently
Muscles stiff, sore, tense and/or achy
Burning, throbbing, shooting or stabbing muscle pain
Muscle cramps or spasms (involuntary or after exertion/exercise)
Is muscle pain or stiffness greater in the morning than other times of the day?
Specific points on body feel sore when pressed
Feel unrefreshed upon awakening
Headaches
Pain at the sides of your head or in your face especially when awakening
Your jaw clicks or pops
Muscle twitch or tremor — eyelids, thumb, calf muscle
Irresistible urge to move legs
Legs move during sleep
Unpleasant crawling sensation inside calves when lying down
Hand and wrist numbness or pain (e.g., interferes with writing or with buttoning or unbuttoning your clothes)
Feeling of "pins and needles" in your thumb and first three fingers
Pain in forearm and sometimes in shoulder

Rows	No/ Rarely	Occasionally	Often	Frequently
Head feels heavy
Dizziness
Difficulty bending over, standing up from sitting, rolling over in bed and/or turning your head from side to side
Your hands tremble, ever so slightly, for no apparent reason
You feel like you're wearing heavy weights on your feet when walking
Bump into things, trip, stumble and feel clumsy
Difficulty breathing
Difficulty swallowing
People tell you to speak up because they have trouble hearing you
Speaking and forming words does not feel automatic
Need 10-12 hours of sleep to feel rested
Lack strength (your grip is weak, holding your head or picking your arms up takes effort)

Rows	No	Yes
Hands get tired when you write and your handwriting is less legible and smaller than it used to be
Muscles in arms and legs seem softer and smaller
Is your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be?
Do you find yourself moving slower than you used to?

Rows	No/ Rarely	Occasionally	Often	Frequently
Difficulty absorbing new information
Tend to forget things
Trouble thinking or concentrating
Easily distracted
Do you have a tendency to become frustrated quickly
Inability to sit still for any length of time, even at mealtime
Finishing tasks is easier said than done
Do you have more trouble solving problems or managing your time than usual
Low tolerance for stress and otherwise ordinary problems

Rows	No/ Rarely	Occasionally	Often	Frequently
Sensation of not emptying your bladder completely
Need to urinate less than 2 hours after you have finished urinating
Find yourself needing to stop and start again several times while urinating
Find it difficult to postpone urination
Have a weak urinary stream
Need to push or strain to begin urinating
Dripping after urination
Urge to urinate several times a night

Rows	No	Yes
Anxious, irritable or restless
Numbness, tingling in hands and feet
Easy to anger, resentful
Aggressive or hostile toward family friends

Rows	No	Yes
Abdominal bloating, feeling swollen (e.g., feet)
Temporary weight gain
Breast tenderness, swelling
Appearance of breast lumps
Discharge from nipples
Nausea and/or vomiting
Diarrhea or constipation
Aches and pains (back, joints, etc.)

Rows	No	Yes
Craving for sweets'
Increased appetite or binge eating
Headaches
Being easily overwhelmed, shaky or clumsy
Heart pounding
Dizziness or fainting

Rows	No	Yes
Confused and forgetful to the point that work suffers
Overwhelmed with feelings of sadness and worthlessness
Difficulty sleeping or falling asleep
Engaging in sell destructive behavior

Rows	No	Yes
Cramping in the lower abdomen or pelvic area
Lower abdominal pain is sharp and/or dull or intermittent
Bloating and sense of abdominal fullness
Diarrhea or constipation
Nausea and/or vomiting
Low back and/or legs ache
Headaches
Unusual fatigue (take naps) resulting in missed work
Painful and/or swollen breasts
Scanty blood flow

Rows	No/ Rarely	Occasionally	Often	Frequently
Painful or difficult sexual intercourse
Low abdominal, back and vaginal pain throughout the month
Pelvic pressure or pain while sitting down or standing up, relieved by lying down
Vaginal bleeding other than during your period
Painful bowel movements
Difficult (straining) urination
Abnormal vaginal discharge
Offensive vaginal discharge
Vaginal itching or burning with or without intercourse

Rows	No	Yes
Pain during periods is getting progressively worse
Profuse or prolonged menstrual bleeding
Unable to get pregnant

Rows	No/ Rarely	Occasionally	Often	Frequently
Profuse heavy bleeding during periods
Menstrual blood contains clots and tissue
Bleeding between periods can occur anytime
Periods occur greater than every 35 days
Intense upper stomach pain, lasting several hours at the time you ovulate (approximately day 14 of your cycle)
Bleeding occurs at ovulation (approximately day 14 of your cycle)
Monthly abdominal pain without bleeding
Abundant cervical mucus
Acne and/or oily skin
Overwhelming urges for sexual intercourse
Aggressive feelings