Core Naturopathics | Health Appraisal

Health Appraisal – Brief Patient Form

Welcome to your Health Appraisal Questionnaire

Name Email Phone Number

SECTION 1: GASTROINTESTINAL

Section 1.1 Stomach: Hypoacidity

1. Indigestion

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Excessive belching, burping

Never (0 Points)

Occasionally (1 Points)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Bloating or fullness commencing during or shortly after a meal

Never (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 meal

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Bad breath

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Loss of appetite, or nausea

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. History of anaemia

No (0 Points)

Yes (3 Points)

SECTION 1: GASTROINTESTINAL

Section 1.2 Stomach: Hyperacidity

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

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Feeling hungry just an hour or two after eating

Never (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 caffeine

Never (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 food

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Heartburn aggravated by lying down or bending forward

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Antacids, carbonated beverages, milk, cream or food relieve the above symptoms

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Constipation

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Difficulty or pain when swallowing

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

9. Black tarry stools

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

10. Vomiting blood or vomitus has appearance of coffee-grounds

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

SECTION 1: GASTROINTESTINAL

Section 1.3 Small Intestine/Pancreas

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

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Abdominal cramps or aches

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Nausea and/or vomiting

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Excessive passage of gas

Never (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 diarrhoea

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Undigested food in stools

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Stools greasy, smelly or stick to toilet bowl

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Black tarry stools

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

11. Certain foods worsen abdominal symptoms

No (0 Points)

Yes (3 Point)

12. Dry flaky skin and dry brittle hair

No (0 Points)

Yes (3 Point)

13. Difficulty gaining weight

No (0 Points)

Yes (3 Point)

SECTION 1: GASTROINTESTINAL

Section 1.4 Colon

1. Lower abdominal pain, cramping and/or spasms

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Lower abdominal pain relieved by passing gas or stool

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Excessive gas and bloating

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Certain foods or stress aggravate lower abdominal pain

Never (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 constipation

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Sensation of incomplete emptying of bowel

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

9. Extremely narrow stools

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (10 Points)

10. Mucus or pus in stool

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

11. Red blood with bowel movement

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

12. Rectal pain or cramps

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

13. Anal itching

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

SECTION 1: GASTROINTESTINAL

Section 1.5 Liver/Gall Bladder/Pancreas

1. Upper abdominal pain, or pain under ribs

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Bloating or feeling of fullness after eating

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Excessive belching or gas

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Fatty foods cause indigestion or nausea

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Loss of appetite

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Nausea and/or vomiting

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Unexplained itchy skin

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Yellowish discolouration of skin or eyes, or dark coloured urine

N0 (0 Points)

Yes (8 Points)

9. Pale clay-coloured stools

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (8 Points)

10. Fatigue, malaise or weakness

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

11. Fluid retention, oedema

Never (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 hair

No (0 Points)

Yes (3 Point)

14. Red skin, particularly on palms

No (0 Points)

Yes (3 Point)

15. Dry, flaky skin, or dry hair

No (0 Points)

Yes (3 Point)

SECTION 2: ENDOCRINE

Section 2.1 Symptoms of underactive thyroid

1. Fatigue, sluggishness

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Feeling cold, or intolerance to cold

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Swelling or tightness in front of neck

No (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 hair

No (0 Points)

Yes (3 Points)

6. Puffy face, hands or feet

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Gaining of weight, or decreased appetite

No (0 Points)

Yes (3 Points)

8. Low mood

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Difficulty concentrating, poor memory

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Low libido

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

11. Infertility

No (0 Points)

Yes (3 Points)

12. Heavier or more frequent menstrual periods

No (0 Points)

Yes (3 Points)

SECTION 2: ENDOCRINE

Section 2.2 Symptoms of overactive thyroid

1. Fatigue, notable weakness in limbs

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Feeling hot, or intolerance to heat, sweaty

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Swelling or tightness in front of neck

No (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 appetite

No (0 Points)

Yes (3 Points)

6. Palpitations

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Nervousness, irritability, restlessness

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Tremor

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Insomnia

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Visual disturbance, problems with eyes, or development of staring gaze

Never (0 Points)

Occasionally (2 Point)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

11. Poor libido

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

12. Light, infrequent or absent menstrual periods

No (0 Points)

Yes (8 Point)

SECTION 2: ENDOCRINE

Section 2.3 Stress, fatigue and adrenals

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

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Feeling irritable or oversensitive

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Feeling overwhelmed, unable to cope

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Low mood, mood swings

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Difficulty concentrating or thinking clearly, memory problems

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Need coffee, tea, tobacco, sugar or chocolate as pick me ups

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Fatigued, tire easily

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Find it hard to get up and going in the morning

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Difficulty staying awake during day

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Insomnia

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

11. Palpitations or chest pain

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

12. Nausea, dizziness

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

13. Change in appetite

Never (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 ‘flu

No (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 drain

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Nasal congestion or discharge

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Sore throat

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Cough with mucus

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Cold sores

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Inflamed or bleeding gums, or swollen, red lips or tongue

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Wounds heal slowly

No (0 Points)

Yes (3 Points)

11. Excessive loss of hair

No (0 Points)

Yes (3 Points)

12. Neck, armpit or groin swelling

Never (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 headache

Never (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 eyes

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Swollen eyes, lips, face, or other body parts

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Localised or general itching – eyes, ears, throat, nose, skin

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Rashes or eczema

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

7. Clear watery discharge from nose or eyes

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

8. Sneezing, coughing or wheezing

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Irritability, fatigue

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

10. Certain foods worsen symptoms, or
cause palpitations

No (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 benzoate

Never (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. Caffeine

Never (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 odours

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Even small amounts of alcohol

Never (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?

SECTION 5: BRAIN AND NERVOUS SYSTEM

Section 5.1 Neurological

1. Headache

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Light-headedness, fainting

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

3. Ringing or buzzing in ears

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Trembling hands

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Weakness

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

6. Numbness, pins and needles, or tingling in limbs

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (4 Points)

Frequently / Daily (6 Points)

7. Unsteady on feet

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (6 Points)

Frequently / Daily (8 Points)

8. Easily fatigued

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

9. Poor hand coordination

Never (0 Points)

Occasionally (2 Points)

Moderately / Often (6 Points)

Frequently / Daily (8 Points)

10. Convulsions, seizures or funny turns

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

11. Difficulty concentrating, confused, poor memory

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

12. Clumsy

Never (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 taste

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

15. Slow or slurred speech

Never (0 Points)

Occasionally (4 Points)

Moderately / Often (8 Points)

Frequently / Daily (10 Points)

16. Incontinence

Never (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. Divorce

No (0 Points)

Yes (4 Points)

2. Separation from partner

N0 (0 Points)

Yes (4 Points)

3. Marriage

N0 (0 Points)

Yes (3 Points)

4. Death of close family member or friend

N0 (0 Points)

Yes (4 Points)

5. Loss of work, retirement or starting a new job

N0 (0 Points)

Yes (3 Points)

6. Bankruptcy, or a major change in finances

N0 (0 Points)

Yes (3 Points)

7. Moving house

N0 (0 Points)

Yes (2 Points)

8. Major personal injury or illness

N0 (0 Points)

Yes (3 Points)

9. Violations of the law

N0 (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 excessively

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Live or work in a stressful environment

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Suffer from constant pain or discomfort

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Eat chocolate or drink caffeine in the evenings

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Have difficulty falling asleep or staying asleep

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

6. Eat after 8pm

Never (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 fidgety

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

2. Have a short attention span

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

3. Find it difficult to relax

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

4. Experience mental confusion or sluggishness

Never (0 Points)

Occasionally (1 Point)

Moderately / Often (2 Points)

Frequently / Daily (3 Points)

5. Have or had learning difficulties

N0 (0 Points)

Yes (3 Points)

6. Have food allergies

N0 (0 Points)

Yes (2 Points)

Time is Up!

May 18, 2020

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Health Appraisal – Brief Patient Form

Health Appraisal – Brief Patient Form

SECTION 1: GASTROINTESTINAL

Section 1.1 Stomach: Hypoacidity

SECTION 1: GASTROINTESTINAL

Section 1.2 Stomach: Hyperacidity

SECTION 1: GASTROINTESTINAL

Section 1.3 Small Intestine/Pancreas

SECTION 1: GASTROINTESTINAL

Section 1.4 Colon

SECTION 1: GASTROINTESTINAL

Section 1.5 Liver/Gall Bladder/Pancreas

SECTION 2: ENDOCRINE

Section 2.1 Symptoms of underactive thyroid

SECTION 2: ENDOCRINE

Section 2.2 Symptoms of overactive thyroid

SECTION 2: ENDOCRINE

Section 2.3 Stress, fatigue and adrenals

SECTION 3: IMMUNE

Section 3.1 Low immunity

SECTION 3: IMMUNE

Section 3.2 Allergy

SECTION 4: DETOXIFICATION (capacity)

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

SECTION 5: BRAIN AND NERVOUS SYSTEM

Section 5.1 Neurological

SECTION 5: BRAIN AND NERVOUS SYSTEM

Section 5.2 Stress history

SECTION 5: BRAIN AND NERVOUS SYSTEM

Section 5.3 Symptoms of insomnia

SECTION 5: BRAIN AND NERVOUS SYSTEM

Section 5.4 Normal, healthy learning and concentration