Health Appraisal Questionnaire Sections 6-10 - 21st Century Total Wellness

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 A

Family, friends, work, hobbies, activiites you hold dear are no longer of interest*

Do you cry?*

Does life look entirely hopeless?*

Would you describe yourself as feeling miserable and sad, unhappy or blue?*

Do you find it hard to make the best of difficult situations?*

Sleep problems - too much or too little sleep*

Changes in your appetite and weight*

Lately you've noticed an inability to think clearly or concentrate*

Difficulty making decisions and/or clarifying and achieving your goals*

Total points*

Section B

Does worrying get you down?*

Does every little thing get on your nerves and wear you out?*

Would you consider yourself a nervous person?*

Do you feel easily agitated?*

Do you shake and tremble?*

Are you keyed up and jittery?*

Do you tremble or feel weak when someone shouts at you?*

Do you become scared of sudden movements or noises at night?*

Do you find yourself sighing a lot?*

Are you awakened out of your sleep by frightening dreams?*

Do frightening thoughts keep coming back in your mind?*

Do you become suddenly scared for no reason?*

Do you break out in a cold sweat?*

"Butterfles in your stomach," nausea and/or diarrhea*

Total Points*

Section C

Do you feel pent up and ready to explode?*

Are you prone to noisy and emotional outbursts?*

Do you do things on impulse?*

Do you go to pieces if you don't control yourself?*

Do little annoyances get on your nerves and make you angry?*

Does it make you angry to have anyone tell you what to do?*

Do you flare up in anger if you can't have what you want right away?*

Total points*

Part VII

Eyes water or tear*

Mucus discharge from the eyes*

Ears ache, itch, feel congested or sore*

Discharge from ears*

Is your nose continually congested?*

Are you prone to loud snoring?*

Does your nose run?*

Nosebleeds*

Hoarse voice*

Do you have to clear your throat?*

Do you feel a choking lump in your throat?*

Do you suffer from severe colds?*

Do frequent colds keep you miserable all winter?*

Flu symptoms last longer than 5 days*

Do infections settle in your lungs?*

Chest discomfort or pain*

Do you experience sudden breathing difficulties?*

Do you struggle with shortness of breath?*

Difficulty exhaling (breathing out)*

Breathlessness followed by coughing during exertion no matter how slight?*

Inability to breath comfortably while lying down*

Do you cough up lots of phlegm?*

Can you hear noisy rattling sounds when breathing in and out?*

Are you troubled with coughing?*

Do you wheeze?*

Do you have severe soaking sweats at night?*

Do your lips and/or nails have a bluish hue?*

Are you sleepy during the day?*

Do you have difficulty concentrating?*

Eyes, ears, nose, throat an dlung symptoms seems associated with specific foods like diary or wheat products*

Eyes, ears, nose, throat and lung symptoms are associated with seasonal changes*

Total points*

Part VIII

Involuntary loss of urine when you cough, lift something or strain during an activity*

Mild lower back ache or pain*

Abdominal achiness or pain*

Pain or burning when urinating*

Rarely feel the urge to urinate*

Feel the need to urinate less tha every two hours during the day or night*

Strong smelling urine*

Back or leg pains are associated with dripping after urination*

Sore or painful genetals*

Urine is a rose color*

Sudden urge to void causes involuntary loss of urine*

Generalized sense of water retention throughout your body*

Total points*

Part IX

Bones throughout your entire body ache, feel tender or sore*

Localized bone pain*

Hands, feet or throat get tight, spasm or feel numb*

Difficulty sitting straight*

Upper back pain*

Lower back pain*

Pain when sitting down or walking*

Find yourself limping or favoring one leg*

Shins hurt during or after exercise*

Total points*

Section B

Are you stiff in the morning when you wake up?*

Difficulty bending down and picking up clothing or anything from the floor*

Joint swelling,pain or stiffness in 1 or more areas (fingers/hands/wrists/elbows/shoulders/toes/arches/ feet/ankles/knees)*

Joints hurt when moving or when carrying weight*

A routine exercise program, like daily walking causes your knees to swell or hurt*

Difficulty opening jars that were previously easy to open*

Discomfort, numbness, prickling or tingling sensation or pain in neck, shoulder or arm*

Intermittent pain or ache on one side of head spreading to cheek, temple, lower jaw, ear, neck or shoulder*

Difficulty chewing food or opening mouth*

Difficulty standing up from a sitting position*

Shooting, arching, tingling pain down the back of leg*

Is it difficult to reach up and get a 5 lb object like a bag of flour from just above your head?*

Injure, strain or sprain easily*

Total points*

Section C

Muscles stiff, sore, tense and/or achy*

Burning, throbbing, shooting or stabbing muscle pain or achy*

Muscle cramps or spasms (involuntary or after exertion/exercise*

Is muscle pain or stiffness greater in the morning than other times of the day?*

Specific points on body feel sore when pressed*

Feel unrefreshed upon awakening*

Headaches*

Pain at the sides of your head or in your face especially when awakening*

Your jaw clicks or pops*

Muscle twitch or tremor - eyelids, thumb, calf muscle*

Irresistible urge to move legs*

Legs move during sleep*

Unpleasant crawling sensation inside calves when lying down*

Hand and wrist numbness or pain (e.g. interferes with writing or buttoning or unbuttoning your clothes)*

Feeling of 'pins and needles' in your thumb and first three fingers*

Pain in forearm and sometimes in shoulder*

Total points*

Part X Section A

Head feels heavy*

Dizziness*

Difficulty bending over, standing up from sitting, rolling over in bed and/or turning your head from side to side*

Your hands tremble, ever so slightly, for no apparent reason*

You feel like you're wearing heavy weights on your feet when walking*

Bump into things, trip, stumble and feel clumsy*

Difficulty breathing*

Difficulty swallowing*

People tell you to speak up because they have trouble hearing you*

Speaking and forming words does not feel automatic*

Need 10-12 hours of sleep to feel rested*

Lack strength (your grip is weak, holding your head or picking your arms up takes effort)*

Hands get tired when you write and your handwriting is less legible and smaller than it used to be*

Muscles in arms and legs seem softer and smaller*

Is your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be?*

Do you find yourself moving slower than you used to?*

Total points*

Section B

Difficulty absorbing new information*

Tend to forget things*

Trouble thinking or concentrating*

Easily distracted*

Do you have a tendency to become frustrated quickly?*

Inability to sit still for any length of time, even at mealtime*

Finishing tasks is easier said than done*

Do you have more trouble solving problems or managing your time than usual?*

Low tolerance for stress and otherwise ordinary problems*

Total points*

Let us know you are human