Health Appraisal Questionnaire Name*Date* Phone*Email* 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 AIndigestion, food repeats on you after you eat*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyExcessive burping, belching and/or bloating following meals*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStomach spasms and cramping during or after eating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyA sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBad taste in your mouth*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySmall amounts of food fill you up immediately*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySkip meals or eat erratically because you have no appetite*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section BStrong emotions, or the thought or smell of food aggravates your stomach or makes it hurt*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel hungry an hour or two after eating a good-sized meal*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStomach pain, burning and/or aching over a period of 1-4 hours after eating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStomach pain, burning and/or aching relieved by eating food, drinking carbonated beverages, cream or mil, or taking antacids*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBurning sensation in the lower part of your chest, especially when lying down or bending forward*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDigestive problems that subside with rest and relaxtion*0 - No8 - YesEating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel a sense of nausea when you eat*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty or pain when swallowing food or beverage*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section CWhen massaging under your rib cage on your left side, there is pain, tenderness or soreness*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIndigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLower abdominal discomfort is relieved with the passage of gas or with a bowel movement*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySpecific foods/beverages aggravate indigestion*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyThe consistency or form of your stool changes (e.g. from narrow to loose) within the course of a day*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStool odor is embarrassing*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUndigested food in your stool*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyThree or more large bowel movements daily*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDiarrhea (frequent loose, watery stool)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBowel movement shortly after eating (within 1 hour)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section DDiscomfort, pain or cramps in your colon (lower abdominal area)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyEmotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyGenerally constipated (or straining during bowel movements)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStool is small, hard and dry*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPass mucus in your stool*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAlternate between constipation and diarrhea*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyRectal pain, itching or cramping*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNo urge to have a bowel movement*0 - No8 - YesAn almost continual need to have a bowel movement*0 - No8 - YesTotal points*Part IIWhen massaging under your rib cage on your right side, there is pain, tenderness or soreness*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAbdominal pain worsens with deep breathing*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPain at night that may move to your back or right shoulder*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBitter fluid repeats after eating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel abdominal discomfort or nausea when eating rich, fatty or fried foods*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyThrobbing temples and/or dull pain in forehead associated with overeating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUnexplained itchy skin that's worse at night*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStool color alternates from clay colored to normal brown*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyGeneral feeling of poor health*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAching muscles not due to exercise*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyRetain fluid and feel swollen around the abdominal area*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyReddened skin, especially palms*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyVery strong body odor*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you embarrassed by your breath*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBruise easily*0 - No8 - YesYellowish cast to eyes*0 - No8 - YesTotal points*Part III Section A Feel cold or chilled - hands, feet or all over - for no apparent reason*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyYour upper eyelids look swollen*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMuscles are weak, cramp and/or tremble*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you forgetful?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you feel like your heart beats slowly?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyReaction time seems slowed down*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIn general, are you disinterested in sex because your desire is low?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel slow-moving, sluggish*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyConstipation*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDryness, discoloration of skin and/or hair?*0 - No8 - YesHave you noticed recently that your voice is deepening?*0 - No8 - YesThick, brittle nails*0 - No8 - YesWeight gain for no apparent reason*0 - No8 - YesOuter third of your eyebrow is thinning or disappearing*0 - No8 - YesSwelling of the neck*0 - No8 - YesTotal points*Section BLingering mild fatigue after exertion or stress*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you find that you get tired and exhaust easily?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCraving for salty foods*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySensitive to minor changes in weather and surroundings*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDizzy when rising or standing up from a kneeling positions*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDark bluish or black circles under your eyes*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHave bouts of nausea with or without vomiting*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCatch colds or infections easily*0 - No8 - YesWounds heal slowly*0 - No8 - YesYour body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel puffy or swollen all over your body*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySkin is gradually tanning w/out exposure to sun or ingestion of high levels of carotene-rich foods / supplements*0 - No8 - YesTotal 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*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyA sudden sense of anxiety when you get hungry*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTingling sensation in your hands*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyA sensation of your heart beating too quickly or forcefully*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyShaky, jittery, hands trembling*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySudden profuse sweating and/or your skin feels clammy*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNightmares possibly associated with going to bed on an empty stomach*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyWake up at night feeling restless*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAgitation, easily upset, nervous*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPoor memory, forgetful*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyConfused or disoriented*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDizzy, faint*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCold or numb*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMild headaches or head pounding*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBlurred vision or double vision*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel clumsy and uncoordinated*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section BFrequent urination during the day and night*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUnusual thirst - feeling like you can't drink enough water*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUnusual hunger - eating all the time*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyVision blurs*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel itchy all over*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTingling or numbness in your feet*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySense of drowsiness, lethargy during the day not associated with missing meals or not sleeping*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyEating starchy foods, even healthy/unprocess. (rice, corn, beans, whole wheat, oats) causes weight gain/prevents weight loss*0 - No8 - YesSores heal slowly*0 - No8 - YesLoss of hair on your legs*0 - No8 - YesTotal Points*Part V Section A Feel jittery*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFirst effort of the day causes pain, pressure, tightness or heaviness around the chest*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyExhaustion with minor exertion*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHeavy sweating (no exertion, no hot flashes)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty catching breath, especially during exercise*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHeart pounding, sensation of heart beating too quickly, too slowly or irregularly*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySwelling in feet, ankles and/or legs comes and goes for no apparent reason*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section BMuscle pain at rest*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCramp-like pains in your ankles, calves or legs*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNumbness, tingling and prickling sensation in hands and feet*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCold feet and/or toes appear blue*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBrief moments of hearing loss*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNausea comes and goe quickly (unrelated to eating)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel worse standing: legs get heavy and fatigued*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLeg discomfort or fatigue relieved by elevating legs*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFingers and toes get numb in cold weather even when protected*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNotice changes in your ability to feel pain or differentiate between sensations of hot or cold*0 - No8 - YesBody hair (on arms, hands, fingers, legs and toes) is thinning or has disappeared*0 - No8 - YesDo you notice a decline in your ability to make decisions, concentrate, focus attention or follow directions?*0 - No8 - YesTotal Points*Let us know you are human