Health Appraisal – Brief Patient Form

Health Appraisal – Brief Patient Form

Welcome to your Health Appraisal Questionnaire

Name Email Phone Number


Section 1.1 Stomach: Hypoacidity

1. Indigestion

2. Excessive belching, burping
3. Bloating or fullness commencing during or shortly after a meal
4. Sensation of food sitting in stomach for a prolonged period after a meal
5. Bad breath
6. Loss of appetite, or nausea
7. History of anaemia


Section 1.2 Stomach: Hyperacidity

1. Stomach pain, burning or aching, 1-4 hours after eating

2. Feeling hungry just an hour or two after eating
3. Indigestion or heartburn from spicy or fatty food, citrus, alcohol, or caffeine
4. Stomach discomfort or pain in response to strong emotions, thoughts, or smell of food
5. Heartburn aggravated by lying down or bending forward
6. Antacids, carbonated beverages, milk, cream or food relieve the above symptoms
7. Constipation
8. Difficulty or pain when swallowing
9. Black tarry stools
10. Vomiting blood or vomitus has appearance of coffee-grounds


Section 1.3 Small Intestine/Pancreas

1. Indigestion, bloating and fullness for several hours after eating

2. Abdominal cramps or aches
3. Nausea and/or vomiting
4. Excessive passage of gas
5. Diarrhoea (loose, watery or frequent bowel movements)
6. Constipation (requiring straining, or a hard, dry or small stool)
7. Alternating constipation and diarrhoea
8. Undigested food in stools
9. Stools greasy, smelly or stick to toilet bowl
10. Black tarry stools
11. Certain foods worsen abdominal symptoms
12. Dry flaky skin and dry brittle hair
13. Difficulty gaining weight


Section 1.4 Colon

1. Lower abdominal pain, cramping and/or spasms

2. Lower abdominal pain relieved by passing gas or stool
3. Excessive gas and bloating
4. Certain foods or stress aggravate lower abdominal pain
5. Diarrhoea (loose, watery or frequent bowel movements)
6. Constipation (requiring straining, or a hard, dry or small stool)
7. Alternating diarrhoea and constipation
8. Sensation of incomplete emptying of bowel
9. Extremely narrow stools
10. Mucus or pus in stool
11. Red blood with bowel movement
12. Rectal pain or cramps
13. Anal itching


Section 1.5 Liver/Gall Bladder/Pancreas

1. Upper abdominal pain, or pain under ribs

2. Bloating or feeling of fullness after eating
3. Excessive belching or gas
4. Fatty foods cause indigestion or nausea
5. Loss of appetite
6. Nausea and/or vomiting
7. Unexplained itchy skin
8. Yellowish discolouration of skin or eyes, or dark coloured urine
9. Pale clay-coloured stools
10. Fatigue, malaise or weakness
11. Fluid retention, oedema
12. Easy bruising, or bleeding (e.g. of gums)
13. Loss or thinning of body hair
14. Red skin, particularly on palms
15. Dry, flaky skin, or dry hair


Section 2.1 Symptoms of underactive thyroid

1. Fatigue, sluggishness

2. Feeling cold, or intolerance to cold
3. Swelling or tightness in front of neck
4. Constipation (requiring straining, or a hard, dry or small stool)
5. Dry skin and hair
6. Puffy face, hands or feet
7. Gaining of weight, or decreased appetite
8. Low mood
9. Difficulty concentrating, poor memory
10. Low libido
11. Infertility
12. Heavier or more frequent menstrual periods


Section 2.2 Symptoms of overactive thyroid

1. Fatigue, notable weakness in limbs

2. Feeling hot, or intolerance to heat, sweaty
3. Swelling or tightness in front of neck
4. Diarrhoea (loose, watery or frequent bowel movements)
5. Weight loss, possibly with increased appetite
6. Palpitations
7. Nervousness, irritability, restlessness
8. Tremor
9. Insomnia
10. Visual disturbance, problems with eyes, or development of staring gaze
11. Poor libido
12. Light, infrequent or absent menstrual periods


Section 2.3 Stress, fatigue and adrenals

1. Feeling stressed, nervous, or tense, or unable to relax

2. Feeling irritable or oversensitive
3. Feeling overwhelmed, unable to cope
4. Low mood, mood swings
5. Difficulty concentrating or thinking clearly, memory problems
6. Need coffee, tea, tobacco, sugar or chocolate as pick me ups
7. Fatigued, tire easily
8. Find it hard to get up and going in the morning
9. Difficulty staying awake during day
10. Insomnia
11. Palpitations or chest pain
12. Nausea, dizziness
13. Change in appetite


Section 3.1 Low immunity

1. Frequent colds or ‘flu

2. Frequent infections in other locations (e.g. bladder, skin)
3. Diarrhoea (loose, watery or frequent bowel movements)
4. Ears continuously drain
5. Nasal congestion or discharge
6. Sore throat
7. Cough with mucus
8. Cold sores
9. Inflamed or bleeding gums, or swollen, red lips or tongue
10. Wounds heal slowly
11. Excessive loss of hair
12. Neck, armpit or groin swelling


Section 3.2 Allergy

1. Migraine or non-migraine headache

2. Sensitivity to light (skin or eyes)
3. Dark circles under eyes
4. Swollen eyes, lips, face, or other body parts
5. Localised or general itching – eyes, ears, throat, nose, skin
6. Rashes or eczema
7. Clear watery discharge from nose or eyes
8. Sneezing, coughing or wheezing
9. Irritability, fatigue
10. Certain foods worsen symptoms, or
cause palpitations


As far as you are aware, do you have a sensitivity or allergy to …

1. The preservatives sodium benzoate or potassium benzoate

2. Tyramine (red wine, cheese, bananas, chocolate)
3. Caffeine
4. Chemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odours
5. Even small amounts of alcohol
6. Do you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents?
7. Alcohol (number of drinks per week)
8. Coffee or other caffeinated drinks (number per day)
9. Smoking (number per day)?
10. If not currently smoking, have you quit smoking in the last year?
11. Recreational drugs?
12. Type of recreation drugs
14. What is your blood type?


Section 5.1 Neurological

1. Headache

2. Light-headedness, fainting
3. Ringing or buzzing in ears
4. Trembling hands
5. Weakness
6. Numbness, pins and needles, or tingling in limbs
7. Unsteady on feet
8. Easily fatigued
9. Poor hand coordination
10. Convulsions, seizures or funny turns
11. Difficulty concentrating, confused, poor memory
12. Clumsy
13. Drooping eyelid(s)
14. Impaired hearing, eyesight, sense of touch, smell or taste
15. Slow or slurred speech
16. Incontinence


Section 5.2 Stress history

In past 2 years have you experienced…
1. Divorce

2. Separation from partner
3. Marriage
4. Death of close family member or friend
5. Loss of work, retirement or starting a new job
6. Bankruptcy, or a major change in finances
7. Moving house
8. Major personal injury or illness
9. Violations of the law


Section 5.3 Symptoms of insomnia

Do you…
1. Have an overactive mind, or worry excessively

2. Live or work in a stressful environment
3. Suffer from constant pain or discomfort
4. Eat chocolate or drink caffeine in the evenings
5. Have difficulty falling asleep or staying asleep
6. Eat after 8pm


Section 5.4 Normal, healthy learning and concentration

Do you…
1. Find if difficult to keep still or are fidgety

2. Have a short attention span
3. Find it difficult to relax
4. Experience mental confusion or sluggishness
5. Have or had learning difficulties
6. Have food allergies