Health Assessment Questionnaire

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After entering contact and 'primary health concerns' information, please select a number for each symptom.  If the symptom does not pertain to you select 0.  If the symptom is mild select 1, if moderate select 2, if severe select 3.

Contact Information

Full Name: *

Email address *

Month *Please select... 01 02 03 04 05 06 07 08 09 10 11 12

Day *Please select... 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year *

Address

City

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Zip

Phone #:

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What are your primary symptoms or concerns

1 *

2 *

3

4

Comments

Category 1: Hyperacidity

Stomach pain, burning or aching after eating0123

Do you frequently use antacids0123

Feeling hungry 1-2 hours after eating0123

Heartburn when lying down or bending forward0123

Temporary relief from antacids, food, milk, carbonated beverages0123

Digestive problems subside with rest and relaxation0123

Heartburn due to spicy foods, chocolate, citrus, peppers, caffeine and alcohol0123

Hyperacidity Total

Hyperacidity Average

Category 2: Hypochlorhydria

Excessive belching, burping or bloating0123

Gas immediately following a meal0123

Difficult bowel movements0123

Offensive breath0123

Excessive sense of fullness during and after meals0123

Difficulty digesting fruits and vegetables0123

Undigested food found in stools0123

Loss of taste for meat; meat sits in stomach 'like a rock'0123

Feel better if you don't eat0123

Fingernails peel, chip or break easily0123

Hypochlorhydria Total

Hypochlorhydria Average

Category 3: Small Intestine/Pancreas

Roughage and fiber cause constipation0123

Indigestion and fullness lasts 2-4 hours after eating0123

Pain, tenderness, soreness on the left side under ribcage0123

Excessive passage of gas0123

Nausea and/or vomiting0123

Stool is undigested, poorly formed, greasy, contains mucus or foul smelling0123

Specific foods make you feel bloated or tired0123

Wheat or grain sensitivity0123

Dairy sensitivity0123

Small Intestine/Pancreas Total

Small Intestine/Pancreas Average

Category 4: Colon

Constipation0123

Diarrhea0123

Feeling that bowels do not empty completely0123

Lower abdominal pain relieved by passing stool or gas0123

Alternating constipation and diarrhea0123

Dry, hard or small stool0123

Thick coating or "fuzzy" debris on tongue0123

Pass foul smelling gas0123

More than 3 bowel movements per day0123

Use laxatives frequently0123

History of antibiotic use0123

Anus itches0123

Fungal or yeast infections0123

Toe nail fungus, athletes foot or jock itch0123

Blood in stool0123

Colon Total

Colon Average

Category 5: Gall Bladder

Greasy or fatty foods cause distress (nausea, fatigue, excessive fullness or heaviness)0123

Lower bowel gas or bloating several hours after eating0123

Bitter or metallic taste in mouth, especially in the morning0123

Unexplained itchy skin0123

Yellowish coloring to the sclera (white part) of the eyes0123

Stool color alternates from clay colored to normal brown0123

Reddened skin, especially palms0123

Dry or flaky skin and/or hair0123

History of gallbladder attacks or stones0123

Nausea or motion sickness0123

History of drug or alcohol abuse0123

Have you had your gallbladder removedNoYes

Gallbladder Total

Gallbladder Average

Category 6: Hypoglycemia

Crave sweets during the day0123

Binge or uncontrolled eating0123

Irritable if meals are missed0123

Depend on coffee/caffeine to keep yourself going or get started in the morning0123

Get lightheaded if meals are missed0123

Eating relieves fatigue0123

Agitated, easily upset, nervous0123

Poor memory, forgetful0123

Blurred vision0123

Hypoglycemia Total

Hypoglycemia Average

Category 7: Insulin Resistance

Fatigue after meals0123

Crave sweets during the day0123

Eating sweets does not relieve cravings for sugar0123

Must have sweets after meals0123

Waist is larger than hips0123

Frequent urination0123

Frequent thirst0123

Family members with diabetes0123 or more

Insulin Resistance Total

Insulin Resistance Average

Category 8: Adrenal Fatigue

Slow starter in the morning0123

Afternoon fatigue0123

Afternoon headaches0123

Dizziness when standing up quickly0123

Headaches with exertion or stress0123

Crave salt0123

Weak nails0123

Can not stay asleep0123

Adrenal Fatigue Total

Adrenal Fatigue Average

Category 9: Adrenal Stress

Can not fall asleep0123

Perspire easily0123

Under high amounts of stress0123

Tend to gain weight when under stress0123

Skip meals or forget to eat0123

Anxiety or palpitations brought on by stress or caffeine0123

Adrenal Stress Total

Adrenal Stress Average

Category 10: Underactive Thyroid

Tired, sluggish0123

Feel cold - hands, feet, all over0123

Require excessive amounts of sleep to function properly0123

Weight gain even with low-calorie diet0123

Gain weight easily0123

Difficult, infrequent bowel movements0123

Depression, lack of motivation0123

Morning headaches that wear off as the day progresses0123

Outer third of eyebrows thinning0123

Thinning of hair on scalp, face, genitals or excessive hair falling out0123

Dryness of skin and/or scalp0123

Mental sluggishness0123

Underactive Thyroid Total

Underactive Thyroid Average

Category 11: Overactive Thyroid

Heart palpitations0123

Increased pulse/heart racing even at rest0123

Inward trembling0123

Nervous and emotional0123

Insomnia0123

Night Sweats0123

Difficulty gaining weight0123

Overactive Thyroid Total

Overactive Thyroid Average

Are You Male or Female *MaleFemale

Category 12a: Prostate

Difficult urination or dribbling0123

Frequent urination0123

Pain on the inside of legs or heels0123

Feeling of incomplete bowel elimination0123

Nervous or restless legs at night0123

Prostate Total

Prostate Average

Category 12b: Andropause

Decrease in libido (sex drive)0123

Decrease in spontaneous morning erections0123

Decrease in fullness/hardness of erections0123

Decrease in maintaining erections0123

Spells of mental fatigue0123

Inability to concentrate0123

Episodes of depression0123

Muscle soresess0123

Decrease in physical stamina0123

Unexplained weight gain0123

Increase in fat around chest and hips0123

Sweating attacks0123

More emotional than in past0123

Andropause Total

Andropause Average

Category 13a: Menstruation

Are you perimenopausalYesNo

Do you have variable menstrual cycle lengthsYesNo

Is your cycle longer than 32 daysYesNo

Is your cycle shorter than 24 daysYesNo

Do you have pain and cramping during periods0123

Scanty blood flow0123

Heavy blood flow0123

Breast pain and swelling during menses0123

Pelvic pain during menses0123

Irritable and/or depressed during menses0123

Acne that corresponds with menstrual cycle0123

Facial hair growth0123

Hair loss/thinning0123

Menstruation Total

Menstruation Average

Category 13b: Menopause (Menopausal Females Only)

Are you on hormone replacement therapyYesNo

Do you ever have uterine bleedingYesNo

Hot flashes0123

Mental dullness, "brain fog"0123

Low libido (sex drive)0123

Mood swings0123

Depression0123

Painful intercourse0123

Shrinking breasts0123

Facial hair growth0123

Acne0123

Vaginal pain, dryness or itching0123

Menopause Total

Menopause Average

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