Health Appraisal Questionnaire 1 - 5 - 21st Century Total Wellness

Name*

Date*

Phone*

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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 programs, 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.

For each question, select the number that best describes your symptoms: 0 = No or rarely; You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or less) 1 = Occasionally; Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger 4 = Often; Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it 8 = Frequently; Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis.

Some questions require a Yes or No response.

Part 1

Section A

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*

Total points*

Section B

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 mil, or taking antacids*

Burning sensation in the lower part of your chest, especially when lying down or bending forward*

Digestive problems that subside with rest and relaxtion*

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*

Total points*

Section C

When massaging under your rib cage on your left side, there is pain, tenderness or soreness*

Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal*

Lower abdominal discomfort is relieved with the passage of gas or with a 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)*

Total points*

Section D

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*

Rectal pain, itching or cramping*

No urge to have a bowel movement*

An almost continual need to have a bowel movement*

Total points*

Part II

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*

Bruise easily*

Yellowish cast to eyes*

Total points*

Part III Section A

Feel cold or chilled - hands, feet or all over - for 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*

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*

Total points*

Section B

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 surroundings*

Dizzy when rising or standing up from a kneeling positions*

Dark bluish or black circles under your eyes*

Have bouts of nausea with or without vomiting*

Catch colds or infections easily*

Wounds heal slowly*

Your body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful*

Feel puffy or swollen all over your body*

Skin is gradually tanning w/out exposure to sun or ingestion of high levels of carotene-rich foods / supplements*

Total points*

Part IV Section A

When you miss meals or go without food for extending periods of time, do you experience any of the following symptoms?

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*

Total points*

Section B

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*

Eating starchy foods, even healthy/unprocess. (rice, corn, beans, whole wheat, oats) causes weight gain/prevents weight loss*

Sores heal slowly*

Loss of hair on your legs*

Total Points*

Part V Section A

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*

Total points*

Section B

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 goe 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*

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?*

Total Points*

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