Health Appraisal Questionnaire Sections 6-10 Name*Date* Email* Phone*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 VI Section AFamily, friends, work, hobbies, activiites you hold dear are no longer of interest*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you cry?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDoes life look entirely hopeless?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyWould you describe yourself as feeling miserable and sad, unhappy or blue?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you find it hard to make the best of difficult situations?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySleep problems - too much or too little sleep*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyChanges in your appetite and weight*0 - No8 - YesLately you've noticed an inability to think clearly or concentrate*0 - No8 - YesDifficulty making decisions and/or clarifying and achieving your goals*0 - No8 - YesTotal points*Section BDoes worrying get you down?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDoes every little thing get on your nerves and wear you out?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyWould you consider yourself a nervous person?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you feel easily agitated?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you shake and tremble?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you keyed up and jittery?*0 - No8 - YesDo you tremble or feel weak when someone shouts at you?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you become scared of sudden movements or noises at night?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you find yourself sighing a lot?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you awakened out of your sleep by frightening dreams?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo frightening thoughts keep coming back in your mind?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you become suddenly scared for no reason?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you break out in a cold sweat?*0 - No or rarely1 - Occasionally4 - Often8 - Frequently"Butterfles in your stomach," nausea and/or diarrhea*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal Points*Section CDo you feel pent up and ready to explode?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you prone to noisy and emotional outbursts?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you do things on impulse?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you go to pieces if you don't control yourself?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo little annoyances get on your nerves and make you angry?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDoes it make you angry to have anyone tell you what to do?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you flare up in anger if you can't have what you want right away?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Part VIIEyes water or tear*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMucus discharge from the eyes*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyEars ache, itch, feel congested or sore*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDischarge from ears*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIs your nose continually congested?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you prone to loud snoring?*0 - No8 - YesDoes your nose run?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNosebleeds*0 - No8 - YesHoarse voice*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you have to clear your throat?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you feel a choking lump in your throat?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you suffer from severe colds?*0 - No8 - YesDo frequent colds keep you miserable all winter?*0 - No8 - YesFlu symptoms last longer than 5 days*0 - No8 - YesDo infections settle in your lungs?*0 - No8 - YesChest discomfort or pain*0 - No8 - YesDo you experience sudden breathing difficulties?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you struggle with shortness of breath?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty exhaling (breathing out)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBreathlessness followed by coughing during exertion no matter how slight?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyInability to breath comfortably while lying down*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you cough up lots of phlegm?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyCan you hear noisy rattling sounds when breathing in and out?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you troubled with coughing?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you wheeze?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you have severe soaking sweats at night?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo your lips and/or nails have a bluish hue?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAre you sleepy during the day?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you have difficulty concentrating?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyEyes, ears, nose, throat an dlung symptoms seems associated with specific foods like diary or wheat products*0 - No8 - YesEyes, ears, nose, throat and lung symptoms are associated with seasonal changes*0 - No8 - YesTotal points*Part VIIIInvoluntary loss of urine when you cough, lift something or strain during an activity*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMild lower back ache or pain*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyAbdominal achiness or pain*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPain or burning when urinating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyRarely feel the urge to urinate*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel the need to urinate less tha every two hours during the day or night*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyStrong smelling urine*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBack or leg pains are associated with dripping after urination*0 - No8 - YesSore or painful genetals*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUrine is a rose color*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySudden urge to void causes involuntary loss of urine*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyGeneralized sense of water retention throughout your body*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Part IXBones throughout your entire body ache, feel tender or sore*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLocalized bone pain*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHands, feet or throat get tight, spasm or feel numb*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty sitting straight*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUpper back pain*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLower back pain*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPain when sitting down or walking*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFind yourself limping or favoring one leg*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyShins hurt during or after exercise*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Section BAre you stiff in the morning when you wake up?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty bending down and picking up clothing or anything from the floor*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyJoint swelling,pain or stiffness in 1 or more areas (fingers/hands/wrists/elbows/shoulders/toes/arches/ feet/ankles/knees)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyJoints hurt when moving or when carrying weight*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyA routine exercise program, like daily walking causes your knees to swell or hurt*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty opening jars that were previously easy to open*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDiscomfort, numbness, prickling or tingling sensation or pain in neck, shoulder or arm*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIntermittent pain or ache on one side of head spreading to cheek, temple, lower jaw, ear, neck or shoulder*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty chewing food or opening mouth*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty standing up from a sitting position*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyShooting, arching, tingling pain down the back of leg*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIs it difficult to reach up and get a 5 lb object like a bag of flour from just above your head?*0 - No8 - YesInjure, strain or sprain easily*0 - No8 - YesTotal points*Section CMuscles stiff, sore, tense and/or achy*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBurning, throbbing, shooting or stabbing muscle pain or achy*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMuscle cramps or spasms (involuntary or after exertion/exercise*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIs muscle pain or stiffness greater in the morning than other times of the day?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySpecific points on body feel sore when pressed*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeel unrefreshed upon awakening*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHeadaches*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPain at the sides of your head or in your face especially when awakening*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyYour jaw clicks or pops*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyMuscle twitch or tremor - eyelids, thumb, calf muscle*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyIrresistible urge to move legs*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLegs move during sleep*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyUnpleasant crawling sensation inside calves when lying down*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHand and wrist numbness or pain (e.g. interferes with writing or buttoning or unbuttoning your clothes)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFeeling of 'pins and needles' in your thumb and first three fingers*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPain in forearm and sometimes in shoulder*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Part X Section AHead feels heavy*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDizziness*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty bending over, standing up from sitting, rolling over in bed and/or turning your head from side to side*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyYour hands tremble, ever so slightly, for no apparent reason*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyYou feel like you're wearing heavy weights on your feet when walking*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyBump into things, trip, stumble and feel clumsy*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty breathing*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDifficulty swallowing*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyPeople tell you to speak up because they have trouble hearing you*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlySpeaking and forming words does not feel automatic*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyNeed 10-12 hours of sleep to feel rested*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLack strength (your grip is weak, holding your head or picking your arms up takes effort)*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyHands get tired when you write and your handwriting is less legible and smaller than it used to be*0 - No8 - YesMuscles in arms and legs seem softer and smaller*0 - No8 - YesIs your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be?*0 - No8 - YesDo you find yourself moving slower than you used to?*0 - No8 - YesTotal points*Section BDifficulty absorbing new information*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTend to forget things*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTrouble thinking or concentrating*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyEasily distracted*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you have a tendency to become frustrated quickly?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyInability to sit still for any length of time, even at mealtime*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyFinishing tasks is easier said than done*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyDo you have more trouble solving problems or managing your time than usual?*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyLow tolerance for stress and otherwise ordinary problems*0 - No or rarely1 - Occasionally4 - Often8 - FrequentlyTotal points*Let us know you are human