Health Appraisal – Brief Patient Form Welcome to your Health Appraisal Questionnaire Name Email Phone Number SECTION 1: GASTROINTESTINALSection 1.1 Stomach: Hypoacidity1. IndigestionNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Excessive belching, burpingNever (0 Points)Occasionally (1 Points)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Bloating or fullness commencing during or shortly after a mealNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Sensation of food sitting in stomach for a prolonged period after a mealNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Bad breathNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Loss of appetite, or nauseaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. History of anaemiaNo (0 Points)Yes (3 Points) SECTION 1: GASTROINTESTINAL Section 1.2 Stomach: Hyperacidity 1. Stomach pain, burning or aching, 1-4 hours after eatingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Feeling hungry just an hour or two after eatingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Indigestion or heartburn from spicy or fatty food, citrus, alcohol, or caffeineNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Stomach discomfort or pain in response to strong emotions, thoughts, or smell of foodNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Heartburn aggravated by lying down or bending forwardNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Antacids, carbonated beverages, milk, cream or food relieve the above symptomsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. ConstipationNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Difficulty or pain when swallowingNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 9. Black tarry stoolsNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 10. Vomiting blood or vomitus has appearance of coffee-groundsNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) SECTION 1: GASTROINTESTINALSection 1.3 Small Intestine/Pancreas1. Indigestion, bloating and fullness for several hours after eatingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Abdominal cramps or achesNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Nausea and/or vomitingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Excessive passage of gasNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Diarrhoea (loose, watery or frequent bowel movements)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Constipation (requiring straining, or a hard, dry or small stool)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Alternating constipation and diarrhoeaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Undigested food in stoolsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Stools greasy, smelly or stick to toilet bowlNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. Black tarry stoolsNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 11. Certain foods worsen abdominal symptomsNo (0 Points)Yes (3 Point) 12. Dry flaky skin and dry brittle hairNo (0 Points)Yes (3 Point) 13. Difficulty gaining weightNo (0 Points)Yes (3 Point) SECTION 1: GASTROINTESTINALSection 1.4 Colon1. Lower abdominal pain, cramping and/or spasmsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Lower abdominal pain relieved by passing gas or stoolNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Excessive gas and bloatingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Certain foods or stress aggravate lower abdominal painNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Diarrhoea (loose, watery or frequent bowel movements)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Constipation (requiring straining, or a hard, dry or small stool)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Alternating diarrhoea and constipationNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Sensation of incomplete emptying of bowelNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 9. Extremely narrow stoolsNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (10 Points) 10. Mucus or pus in stoolNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 11. Red blood with bowel movementNever (0 Points)Occasionally (2 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 12. Rectal pain or crampsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 13. Anal itchingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) SECTION 1: GASTROINTESTINALSection 1.5 Liver/Gall Bladder/Pancreas1. Upper abdominal pain, or pain under ribsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Bloating or feeling of fullness after eatingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Excessive belching or gasNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Fatty foods cause indigestion or nauseaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Loss of appetiteNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Nausea and/or vomitingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Unexplained itchy skinNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Yellowish discolouration of skin or eyes, or dark coloured urineN0 (0 Points)Yes (8 Points) 9. Pale clay-coloured stoolsNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (8 Points) 10. Fatigue, malaise or weaknessNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 11. Fluid retention, oedemaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 12. Easy bruising, or bleeding (e.g. of gums)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 13. Loss or thinning of body hairNo (0 Points)Yes (3 Point) 14. Red skin, particularly on palmsNo (0 Points)Yes (3 Point) 15. Dry, flaky skin, or dry hairNo (0 Points)Yes (3 Point) SECTION 2: ENDOCRINESection 2.1 Symptoms of underactive thyroid1. Fatigue, sluggishnessNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Feeling cold, or intolerance to coldNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Swelling or tightness in front of neckNo (0 Points)Yes (8 Points) 4. Constipation (requiring straining, or a hard, dry or small stool)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Dry skin and hairNo (0 Points)Yes (3 Points) 6. Puffy face, hands or feetNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Gaining of weight, or decreased appetiteNo (0 Points)Yes (3 Points) 8. Low moodNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Difficulty concentrating, poor memoryNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. Low libidoNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 11. InfertilityNo (0 Points)Yes (3 Points) 12. Heavier or more frequent menstrual periodsNo (0 Points)Yes (3 Points) SECTION 2: ENDOCRINESection 2.2 Symptoms of overactive thyroid1. Fatigue, notable weakness in limbsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Feeling hot, or intolerance to heat, sweatyNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Swelling or tightness in front of neckNo (0 Points)Yes (8 Points) 4. Diarrhoea (loose, watery or frequent bowel movements)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Weight loss, possibly with increased appetiteNo (0 Points)Yes (3 Points) 6. PalpitationsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Nervousness, irritability, restlessnessNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. TremorNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. InsomniaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. Visual disturbance, problems with eyes, or development of staring gazeNever (0 Points)Occasionally (2 Point)Moderately / Often (4 Points)Frequently / Daily (6 Points) 11. Poor libidoNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 12. Light, infrequent or absent menstrual periodsNo (0 Points)Yes (8 Point) SECTION 2: ENDOCRINE Section 2.3 Stress, fatigue and adrenals 1. Feeling stressed, nervous, or tense, or unable to relaxNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Feeling irritable or oversensitiveNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Feeling overwhelmed, unable to copeNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Low mood, mood swingsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Difficulty concentrating or thinking clearly, memory problemsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Need coffee, tea, tobacco, sugar or chocolate as pick me upsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Fatigued, tire easilyNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Find it hard to get up and going in the morningNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Difficulty staying awake during dayNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. InsomniaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 11. Palpitations or chest painNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 12. Nausea, dizzinessNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 13. Change in appetiteNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) SECTION 3: IMMUNE Section 3.1 Low immunity 1. Frequent colds or ‘fluNo (0 Points)Yes (3 Points) 2. Frequent infections in other locations (e.g. bladder, skin)No (0 Points)Yes (3 Points) 3. Diarrhoea (loose, watery or frequent bowel movements)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Ears continuously drainNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Nasal congestion or dischargeNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Sore throatNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Cough with mucusNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Cold soresNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Inflamed or bleeding gums, or swollen, red lips or tongueNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. Wounds heal slowlyNo (0 Points)Yes (3 Points) 11. Excessive loss of hairNo (0 Points)Yes (3 Points) 12. Neck, armpit or groin swellingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (6 Points) SECTION 3: IMMUNE Section 3.2 Allergy 1. Migraine or non-migraine headacheNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Sensitivity to light (skin or eyes)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Dark circles under eyesNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Swollen eyes, lips, face, or other body partsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Localised or general itching – eyes, ears, throat, nose, skinNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Rashes or eczemaNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 7. Clear watery discharge from nose or eyesNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 8. Sneezing, coughing or wheezingNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Irritability, fatigueNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 10. Certain foods worsen symptoms, or cause palpitationsNo (0 Points)Yes (3 Points) SECTION 4: DETOXIFICATION (capacity) As far as you are aware, do you have a sensitivity or allergy to …1. The preservatives sodium benzoate or potassium benzoateNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Tyramine (red wine, cheese, bananas, chocolate)Never (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. CaffeineNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Chemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odoursNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Even small amounts of alcoholNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Do you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents?No (0 Points)Yes (3 Points) 7. Alcohol (number of drinks per week)Zero (0 Points)1 -7 (1 Point)8-14 (2 Points)15+ (3 Points) 8. Coffee or other caffeinated drinks (number per day)Zero (0 Points)1-2 (1 Point)3-4 (2 Points)5+ (3 Points) 9. Smoking (number per day)?Zero (0 Points)1-8 (3 Points)9-19 (3 Points)20+ (6 Points) 10. If not currently smoking, have you quit smoking in the last year?No (0 Points)Yes (2 Points) 11. Recreational drugs?No (0 Points)Yes (3 Points) 12. Type of recreation drugs 14. What is your blood type?Please select your answerA+A-B+B-O+O-AB+AB-Not Sure SECTION 5: BRAIN AND NERVOUS SYSTEM Section 5.1 Neurological 1. HeadacheNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Light-headedness, faintingNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 3. Ringing or buzzing in earsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Trembling handsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. WeaknessNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 6. Numbness, pins and needles, or tingling in limbsNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 7. Unsteady on feetNever (0 Points)Occasionally (2 Points)Moderately / Often (6 Points)Frequently / Daily (8 Points) 8. Easily fatiguedNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 9. Poor hand coordinationNever (0 Points)Occasionally (2 Points)Moderately / Often (6 Points)Frequently / Daily (8 Points) 10. Convulsions, seizures or funny turnsNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 11. Difficulty concentrating, confused, poor memoryNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 12. ClumsyNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 13. Drooping eyelid(s)Never (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) 14. Impaired hearing, eyesight, sense of touch, smell or tasteNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 15. Slow or slurred speechNever (0 Points)Occasionally (4 Points)Moderately / Often (8 Points)Frequently / Daily (10 Points) 16. IncontinenceNever (0 Points)Occasionally (2 Points)Moderately / Often (4 Points)Frequently / Daily (6 Points) SECTION 5: BRAIN AND NERVOUS SYSTEM Section 5.2 Stress history In past 2 years have you experienced…1. DivorceNo (0 Points)Yes (4 Points) 2. Separation from partnerN0 (0 Points)Yes (4 Points) 3. MarriageN0 (0 Points)Yes (3 Points) 4. Death of close family member or friendN0 (0 Points)Yes (4 Points) 5. Loss of work, retirement or starting a new jobN0 (0 Points)Yes (3 Points) 6. Bankruptcy, or a major change in financesN0 (0 Points)Yes (3 Points) 7. Moving houseN0 (0 Points)Yes (2 Points) 8. Major personal injury or illnessN0 (0 Points)Yes (3 Points) 9. Violations of the lawN0 (0 Points)Yes (2 Points) SECTION 5: BRAIN AND NERVOUS SYSTEM Section 5.3 Symptoms of insomnia Do you…1. Have an overactive mind, or worry excessivelyNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Live or work in a stressful environmentNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Suffer from constant pain or discomfortNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Eat chocolate or drink caffeine in the eveningsNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Have difficulty falling asleep or staying asleepNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 6. Eat after 8pmNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) SECTION 5: BRAIN AND NERVOUS SYSTEM Section 5.4 Normal, healthy learning and concentration Do you…1. Find if difficult to keep still or are fidgetyNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 2. Have a short attention spanNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 3. Find it difficult to relaxNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 4. Experience mental confusion or sluggishnessNever (0 Points)Occasionally (1 Point)Moderately / Often (2 Points)Frequently / Daily (3 Points) 5. Have or had learning difficultiesN0 (0 Points)Yes (3 Points) 6. Have food allergiesN0 (0 Points)Yes (2 Points) Time is Up! May 18, 2020