Health Appraisal Questionnaire

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Details
Diet
Lifestyle
Medications
Upper GIT
Liver and gallbladder
Small intestine
Large intestine
Mineral needs
Essential fatty acids
Sugar handling
Vitamin need
Adrenal
Pituitary
Thyroid
Men only
Women only
Cardiovascular
Kidney and bladder
Immune system

Details

First name

Last name

Diet

Alcohol*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Alcohol score

Artificial sweetners*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Artificial sweetners score

Candy, desserts, refined sugar*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Candy, desserts, refined sugar score

Carbonated beverages*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Carbonated beverages score

Chewing tobacco*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Chewing tobacco score

Cigarettes*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Cigarettes score

Cigars / pipes*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Cigars / pipes score

Caffeinated beverages*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Caffeinated beverages score

Fast foods*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Fast foods score

Fried foods*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Fried foods score

Luncheon meats*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Luncheon meats score

Margarine*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Margarine score

Milk products*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Milk products score

Radiation exposure*

Yes

Radiation exposure score

Refined flour / baked goods*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Refined flour / baked goods score

Vitamins and minerals*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Vitamins and minerals score

Water, distilled*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Water distilled score

Water, tap*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Water tap score

Water, well*

Do not use

Consume or use 2-3 times a month

Consume or use weekly

Consume or use daily

Water well score

Diet often for weight control*

Never

Occassionaly

Frequently

Constantly

Diet often for weight control score

Diet total symptom burden

Lifestyle

Exercise per week*

2 or more times a week

1 time a week

1 or 2 times a month

Never, less than once a month

Exercise per week score

Changed jobs*

Over 12 months ago

Within last 12 months

Within last 6 months

Within last 2 months

Changed jobs score

Divorced*

Never, over 2 years ago

Within last 2 years

Within last year

Within last 6 months

Divorced score

Work over 60 hours a week*

Never

Occasionally

Usually

Always

Work over 60 hours a week score

Lifestyle total symptom burden

Medications

Indicate any medications you're currently taking or have taken in the last month

Antacids*

Yes

Antacids score

Anti-anxiety medications*

Yes

Anti-anxiety medications score

Antibiotics*

Yes

Antibiotics score

Anticonvulsants*

Yes

Anticonvulsants score

Antidepressants*

Yes

Antidepressants score

Antifungals*

Yes

Antifungals score

Aspirin / Ibuprofen*

Yes

Aspirin / Ibuprofen score

Asthma inhalers*

Yes

Asthma inhalers score

Beta blockers*

Yes

Beta blockers score

Birth control pills / Implant contraceptives*

Yes

Birth control pills / implant contraceptives score

Chemotherapy*

Yes

Chemotherapy score

Cholesterol lowering medications*

Yes

Cholesterol lowering medications score

Cortisone / steroids*

Yes

Cortisone / steroids score

Diabetic medications / Insulin*

Yes

Diabetic medications / insulin score

Diuretics*

Yes

Diuretics score

Oestrogen or progesterone (pharmaceutical prescription)*

Yes

Oestrogen or progesterone (pharma) score

Oestrogen or progesterone (natural)*

Yes

Oestrogen or progesterone (natural) score

Heart medications*

Yes

Heart medications score

High blood pressure medications*

Yes

High blood pressure medications score

Laxatives*

Yes

Laxatives score

Recreational drugs*

Yes

Recreational drugs score

Relaxants / Sleeping pills*

Yes

Relaxants / sleeping pills score

Testosterone (natural or prescription)*

Yes

Testosterone (natural or prescription) score

Thyroid medication*

Yes

Thyroid medication score

Panadol (Acetaminophen)*

Yes

Panadol (Acetominophen) score

Ulcer medications*

Yes

Ulcer medications score

Viagra (Sidenafal citrate)*

Yes

Viagra (Sidenafal) score

Medication total symptom burden

Upper GIT

Belching or gas within 1 hour after eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Belching or gas within 1 hour after eating score

Heartburn or acid reflux*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Heartburn or acid reflux score

Bloating within one hour after eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bloating within 1 hour after eating score

Vegan diet (no dairy, meat, fish or eggs)*

Yes

Vegan diet score

Bad breath (halitosis)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bad breath (halitosis) score

Loss of taste for meat*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Loss of taste for meat score

Sweat has a strong odour*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sweat has a strong odour score

Stomach upset by taking vitamins*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stomach upset by taking vitamins score

Sense of excess fullness after meals*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sense of fullness after meals score

Feel like skipping breakfast*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feel like skipping breakfast score

Feel better if you don't eat*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feel better if you don't eat score

Sleepy after meals*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sleepy after meals score

Fingernails chip, break or peel easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fingernails chip, break or peel score

Anaemia unresponsive to iron*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Anaemia unresponsive to iron score

Stomach pains or cramps*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stomach pains or cramps score

Diarrhea, chronic*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Diarrhea, chronic score

Diarrhea shortly after meals*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Diarrhea shortly after meals score

Black or tarry coloured stools*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Black or tarry coloured stools score

Undigested food in stool*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Undigested food in stool score

Upper GIT total symptom burden

Liver and gallbladder

Pain between shoulder blades*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain between shoulder blades score

Stomach upset by greasy foods*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stomach upset by greasy foods score

Greasy or shiny stools*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Greasy or shiny stools score

Nausea*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nausea score

Sea, car, airplane or motion sickness*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sea, car, airplane or motion sickness score

History of morning sickness*

Yes

History of morning sickness score

Light or clay coloured stools*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Light or clay coloured stools score

Dry skin, itchy feet, or skin peels on feet*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dry skin, itchy feet, or skin peels on feet score

Headache over eyes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Headache over eyes score

Gallbladder attacks*

Never

Years ago

Within last year

Within past 3 months

Gallbladder attacks score

Gallbladder removed*

Yes

Gallbladder removed score

Bitter taste in mouth, especially after meals*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bitter taste in mouth, especially after meals score

Become sick if you were to drink wine*

Yes

Become sick if you were to drink wine score

Easily intoxicated if you were to drink wine*

Yes

Easily intoxicated if you were to drink wine score

Easily hung over if you were to drink wine*

Yes

Easily hung over if you were to drink wine score

Alcohol per week*

<14

>14

Alcohol per week score

Recovering alcoholic*

Yes

Recovering alcoholic score

History of drug or alcohol abuse*

Yes

History of drug or alcohol abuse score

History of hepatitis*

Yes

History of hepatitis score

Long term use of prescription / recreational drugs*

Yes

Long-term use of prescription / recreational drugs score

Sensitive to chemicals (perfume, cleaning agents, etc)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sensitive to chemicals (perfumes, cleaning agents etc) score

Sensitive to tobacco smoke*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sensitive to tobacco smoke score

Exposure to diesel fumes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Exposure to diesel fumes score

Pain under right side of rib cage*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain under right side of rib cage score

Haemorrhoids or varicose veins*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Haemorrhoids or varicose veins score

Nutrasweet (aspartame) consumption*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nutrasweet (aspartame) consumption score

Sensitive to Nutrasweet (aspartame) *

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sensitive to Nutrasweet (aspartame) score

Chronic fatigue or fibromyalgia*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Chronic fatigue or fibromyalgia score

Liver and gallbladder total symptom burden

Small intestine

Food allergies*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Food allergies score

Abdominal bloating 1-2 hours after eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Abdominal bloating 1-2 hours after eating score

Specific foods make you feel tired or bloated*

Yes

Specific foods make you feel tired or bloated score

Pulse speeds after eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pulse speeds after eating score

Airborne allergies*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Airborne allergies score

Experience hives*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Experience hives score

Sinus congestion, "stuffy head"*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sinus congestion, "stuffy head" score

Crave bread or noodles*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave bread or noodles score

Alternating constipation and diarrhea*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Alternating constipation and diarrhea score

Crohn's disease*

Yes, in the past

Currently mild condition

Severe condition

Crohn's disease score

Wheat or grain sensitivity*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Wheat or grain sensitivity score

Dairy sensitivity*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dairy sensitivity score

Are there foods you could not give up?*

Yes

Are there foods you could not give up? score

Asthma, sinus infections, stuffy nose*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Asthma, sinus infections, stuffy nose score

Bizarre vivid dreams, nightmares*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bizarre vivid dreams, nightmares score

Use of over-the-counter pain medications*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Use of over-the-counter pain medications score

Feel spacey or unreal*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feel spacey or unreal score

Small intestine total symptom burden

Large intestine

Anus itches*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Anus itches score

Coated tongue*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Coated tongue score

Feel worse in moldy or musty place*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feel worse in moldy or musty place score

Taken antibiotic for a total accumulated time of:*

Never

<1 month

<3 months

>3 months

Taken antibiotic for a total accumulated time of score

Fungus or yeast infections*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fungus or yeast infections score

Ringworm, "athletes foot", "jock itch", nail fungus*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Ringworm, "athlete's foot", "jock itch", nail fungus score

Yeast symptoms increase with sugar, starch or alcohol*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Yeast symptoms increase with sugar, starch or alcohol score

Stools hard or difficult to pass*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stools hard or difficult to pass score

History of parasites*

Yes

History of parasites score

Less than one bowel movement per day*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Less than one bowel movement per day score

Stools have corners or edges, are flat or ribbon shaped*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stools have corners or edges, are flat or ribbon shaped score

Stools are not well formed (loose)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Stools are not well formed, "loose" score

Irritable bowel or mucous colitis*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Irritable bowel or mucous colitis score

Blood in stool*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Blood in stool score

Mucous in stool*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Mucous in stool score

Excessive foul smelling lower bowel gas*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessive foul smelling lower bowel gas score

Bad breath or strong body odours*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bad breath or strong body odours score

Painful to press along outer sides of thighs (illiotibial band)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Painful to press along outer sides of thighs (illiotibial band) score

Cramping in lower abdominal region*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cramping in lower abdominal region score

Dark circles under eyes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dark circles under eyes score

Large intestine total symptom burden

Mineral needs

History of carpal tunnel syndrome*

Yes

History of carpal tunnel syndrome score

History of lower right abdominal pains or ileocecal valve problems*

Yes

History of lower right abdominal pains or ileocecal valve problems score

History of stress fracture*

Yes

History of stress fracture score

Bone loss (reduced density on bone scan)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bone loss (reduced density on bone scan) score

Are you shorter than you used to be?*

Yes

Are you shorter than you used to be? score

Calf, foot or toe cramps at rest*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Calf, foot or toe cramps at rest score

Cold sores, fever blisters, or herpes lesions*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cold sores, fever blisters, or herpes lesions score

Frequent fevers*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Frequent fevers score

Frequent skin rashes and/or hives*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Frequent skin rashes and/or hives score

Herniated disc*

Yes

Herniated disc score

Excessively flexible joints, "double jointed"*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessively flexible joints, "double jointed" score

Joints pop or click*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Joints pop or click score

Pain or swelling in joints*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain or swelling in joints score

Bursitis or tendonitis*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bursitis or tendonitis score

History of bone spurs*

Yes

History of bone spurs score

Morning stiffness*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Morning stiffness score

Nausea with vomiting*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nausea with vomiting score

Crave chocolate*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave chocolate score

Feet have a strong odour*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feet have a strong odour score

History of anaemia*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

History of anaemia score

Whites of eyes (sclera) blue tinted*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Whites of eyes (sclera) blue tinted score

Hoarseness*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Hoarseness score

Difficulty swallowing*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty swallowing score

Lump in throat*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Lump in throat score

Dry mouth, nose and/or eyes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dry mouth, nose and/or eyes score

Gag easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Gag easily score

White spots on fingernails*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

White spots on fingernails score

Cuts heal slowly and/or scar easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cuts heal slowly and/or scar easily score

Decreased sense of taste or smell*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Decreased sense of taste or smell score

Mineral needs total symptom burden

Essential fatty acids

Experience pain relief with aspirin*

Yes

Experience pain relief with aspirin score

Crave fatty or greasy foods*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave fatty or greasy foods score

Low or reduced fat diet*

Never

Years ago

Within past year

Currently

Low or reduced fat diet score

Tension headaches at base of skull*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tension headaches at base of skull score

Headaches when out in the hot sun*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Headaches when out in the hot sun score

Sunburn easily or suffer sun poisoning*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sunburn easily or suffer sun poisoning score

Muscles easily fatigued*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Muscles easily fatigued score

Dry flaky skin or dandruff*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dry flaky skin or dandruff score

Essential fatty acids total symptom burden

Sugar handling

Awaken a few hours after falling asleep, hard to get back to sleep*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Awaken a few hours after falling asleep, hard to get back to sleep score

Crave sweets*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave sweets score

Binge or uncontrolled eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Binge or uncontrolled eating score

Excessive appetite*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessive appetite score

Crave coffee or sugar in the afternoon*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave coffee or sugar in the afternoon score

Sleepy in afternoon*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sleepy in afternoon score

Fatigue that is relieved by eating*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fatigue that is relieved by eating score

Headache if meals are skipped or delayed*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Headache if meals are skipped or delayed score

Irritable before meals*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Irritable before meals score

Shaky if meals delayed*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Shaky if meals delayed score

Family members with diabetes*

None

1 or 2

3 or 4

More than 4

Family members with diabetes score

Frequent thirst*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Frequent thirst score

Frequent urination*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Frequent urination score

Sugar handling total symptom burden

Vitamin need

Muscles become easily fatigued*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Muscles become easily fatigued score

Feel exhausted or sore after moderate exercise*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feel exhausted or sore after moderate exercise score

Vulnerable to insect bites*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Vulnerable to insect bites score

Loss of muscle tone / heaviness in arms or legs*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Loss of muscle tone / heaviness in arms or legs score

Enlarged heart or congestive heart failure*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Enlarged heart or congestive heart failure score

Pulse below 65 BPM*

Yes

Pulse below 65 BPM score

Ringing in the ears (tinnitus)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Ringing in the ears (tinnitus) score

Numbness, tingling or itching in hands or feet*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Numbness, tingling or itching in hands or feet score

Depressed*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Depressed score

Fear of impending doom*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fear of impending doom score

Worrier, apprehensive, anxious*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Worrier, apprehensive, anxious score

Nervous or agitated*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nervous or agitated score

Feelings of insecurity*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feelings of insecurity score

Heart races*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Heart races score

Can hear heart beat on pillow at night*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Can hear heart beat on pillow at night score

Whole body or limb jerk as falling asleep*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Whole body or limb jerk as falling asleep score

Night sweats*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Night sweats score

Restless leg syndrome*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Restless leg syndrome score

Cracks at corner of mouth (cheilosis)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cracks at corner of mouth (cheilosis) score

Fragile skin, easily chafed (as in shaving)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fragile skin, easily chafed (as in shaving) score

Polyps or warts*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Polyps or warts score

MSG sensitivity*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

MSG sensitivity score

Wake up without remembering dreams*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Wake up without remembering dreams score

Small bumps on backs of arms*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Small bumps on backs of arms score

Strong light at night irritates eyes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Strong light at night irritates eyes score

Nose bleeds and/or tend to bruise easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nose bleeds and/or tend to bruise easily score

Bleeding gums especially when brushing teeth*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Bleeding gums especially when brushing teeth score

Vitamin need total symptom burden

Adrenal

Tend to be a "night person"*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tend to be a "night person" score

Difficulty falling asleep*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty falling asleep score

Slow starter in the morning*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Slow starter in the morning score

Tend to be keyed up, trouble calming down*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tend to be keyed up, trouble calming down score

Blood pressure above 120/80*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Blood pressure above 120/80 score

Headache after exercising*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Headache after exercising score

Feeling wired or jittery after drinking coffee*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feeling wired or jittery after drinking coffee score

Clench or grind teeth*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Clench or grind teeth score

Calm on the outside, troubled on the inside*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Calm on the outside, troubled on the inside score

Chronic low back pain, worse with fatigue*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Chronic low back pain, worse with fatigue score

Become dizzy when standing up suddenly*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Become dizzy when standing up suddenly score

Difficulty maintaining manipulative correction*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty maintaining manipulative correction score

Pain after manipulative correction*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain after manipulative correction score

Arthritic tendencies*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Arthritic tendencies score

Crave salty foods*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave salty foods score

Salt foods before tasting*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Salt foods before tasting score

Perspire easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Perspire easily score

Chronic fatigue, or get drowsy often*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Chronic fatigue, or get drowsy often score

Afternoon yawning*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Afternoon yawning score

Afternoon headache*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Afternoon headache score

Asthma, wheezing, or difficulty breathing*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Asthma, wheezing, or difficulty breathing score

Pain on the medial or inner side of the knee*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain on the medial or inner side of the knee score

Tendency to sprain ankles or "shin splints"*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tendency to sprain ankles or "shin splints" score

Tendency to need sunglasses*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tendency to need sunglasses score

Allergies and/or hives*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Allergies and/or hives score

Weakness, dizziness*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Weakness, dizziness score

Adrenal total symptom burden

Pituitary

Height over 6'6"*

Yes

Height over 6'6" score

Early sexual development (before age 10)*

Yes

Early sexual development (before age 10) score

Increased libido*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Increased libido score

Splitting type headache*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Splitting type headache score

Memory failing*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Memory failing score

Tolerate sugar, feel fine when eating sugar*

Yes

Tolerate sugar, feel fine when eating sugar score

Height under 4'10"*

Yes

Height under 4'10" score

Decreased libido*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Decreased libido score

Excessive thirst*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessive thirst score

Weight gain around hips or waist*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Weight gain around hips or waist score

Menstrual disorders*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Menstrual disorders score

Delayed sexual development (after age 13)*

Yes

Delayed sexual development (after age 13) score

Tendency to ulcers or colitis*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Tendency to ulcers or colitis score

Pituitary total symptom burden

Thyroid

Sensitive / allergic to iodine*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sensitive / allergic to iodine score

Difficulty gaining weight, even with large appetite*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty gaining weight, even with large appetite score

Nervous, emotional, can't work under pressure*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Nervous, emotional, can't work under pressure score

Inward trembling*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Inward trembling score

Flush easily*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Flush easily score

Fast pulse at rest*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Fast pulse at rest score

Intolerance to high temperatures*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Intolerance to high temperatures score

Difficulty losing weight*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty losing weight score

Mentally sluggish, reduced initiative*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Mentally sluggish, reduced initiative score

Easily fatigued, sleepy during the day*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Easily fatigued, sleepy during the day score

Sensitive to cold, poor circulation (cold hands and feet)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Sensitive to cold, poor circulation (cold hands and feet) score

Constipation, chronic*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Constipation, chronic score

Excessive hair loss and/or coarse hair*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessive hair loss and/or coarse hair score

Morning headaches, wear off during the day*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Morning headaches, wear off during the day score

Loss of lateral 1/3 of eyebrow*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Loss of lateral 1/3 of eyebrow score

Seasonal sadness*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Seasonal sadness score

Thyroid total symptom burden

Men only

Prostate problems

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Prostate problems score

Difficulty with urination, dribbling

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficulty with urination, dribbling score

Difficult to start and stop urine stream

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Difficult to start and stop urine stream score

Pain or burning with urination

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain or burning with urination score

Waking to urinate at night

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Waking to urinate at night score

Interruption of stream during urination

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Interruption of stream during urination score

Pain on inside of legs or heels

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain on inside of legs or heels score

Feeling of incomplete bowel evacuation

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Feeling of incomplete bowel evacuation score

Decreased sexual function

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Decreased sexual function score

Men only total symptom burden

Women only

Depression during periods

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Depression during periods score

Mood swings associated with periods (PMS)

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Mood swings associated with periods (PMS) score

Crave chocolate around periods

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Crave chocolate around periods score

Breast tenderness associated with cycle

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Breast tenderness associated with cycle score

Excessive menstrual flow

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excessive menstrual flow score

Scanty blood flow during periods

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Scanty blood flow during periods score

Occasional skipped periods

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Occasional skipped periods score

Variations in menstrual cycles

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Variations in menstrual cycles score

Endometriosis

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Endometriosis score

Uterine fibroids

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Uterine fibroids score

Breast fibroids, benign masses

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Breast fibroids, benign masses score

Painful intercourse (dysparenia)

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Painful intercourse (dysparenia) score

Vaginal discharge

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Vaginal discharge score

Vaginal dryness

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Vaginal dryness score

Vaginal itchiness

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Vaginal itchiness score

Gain weight around hips, thighs and buttocks

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Gain weight around hips, thighs and buttocks score

Excess facial or body hair

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Excess facial or body hair score

Hot flashes

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Hot flashes score

Night sweats (in menopausal females)

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Night sweats (in menopausal females) score

Thinning skin

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Thinning skin score

Women only total symptom burden

Cardiovascular

Aware of heavy and/or irregular breathing*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Aware of heavy and/or irregular breathing score

Discomfort at high altitudes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Discomfort at high altitudes score

"Air hunger" or sigh frequently*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

"Air hunger" or sigh frequently score

Compelled to open windows in a closed room*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Compelled to open windows in a closed room score

Shortness of breath with moderate exertion*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Shortness of breath with moderate exertion score

Ankles swell, especially at end of day*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Ankles swell, especially at end of day score

Cough at night*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cough at night score

Blush or face turns red for no reason*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Blush or face turns red for no reason score

Dull pain or tightness in chest and/or radiate into right arm, worse with exertion*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Dull pain or tightness in chest and/or radiate into right arm, worse with exertion score

Muscle cramps with exertion*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Muscle cramps with exertion score

Cardiovascular total symptom burden

Kidney and bladder

Pain in mid-back region*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Pain in mid-back region score

Puffy around the eyes, dark circles under eyes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Puffy around the eyes, dark circles under eyes score

History of kidney stones*

Yes

History of kidney stones score

Cloudy, bloody, or darkened urine*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cloudy, bloody, or darkened urine score

Urine has a strong odour*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Urine has a strong odour score

Kidney and bladder total symptom burden

Immune system

Runny or drippy nose*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Runny or drippy nose score

Catch colds at beginning of winter*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Catch colds at beginning of winter score

Mucous producing cough*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Mucous producing cough score

Frequent colds or flu*

1 or less per year

2-3 times per year

4-5 times per year

6 or more times per year

Frequent colds or flu score

Other infections (sinus, ear, lung, kidney, bladder etc)*

1 or less per year

2-3 times per year

4-5 times per year

6 or more times per year

Other infections (sinus, ear, lung, kidney, bladder etc) score

Never get sick*

Sick only 1 or 2 times in last 2 years

Not sick in last 2 years

Not sick in last 4 years

Not sick in last 7 years

Never get sick score

Acne (adult)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Acne (adult) score

Itchy skin (dermatitis)*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Itchy skin (dermatitis) score

Cysts, boils, rashes*

No, symptom does not occur

Yes, mild or minor symptom, rarely occurs (monthly)

Moderate symptom, occurs occasionally (weekly)

Severe symptom, occurs frequently (daily)

Cysts, boils, rashes score

History of Epstein Barr, Mono, Herpes, Shingles, Chronic fatigue syndrome, Hepatitis or other chronic viral condition*

Yes in the past

Currently mild condition

Severe

History of Epstein Barr, Mono, Herpes, Shingles, Chronic fatigue syndrome, Hepatitis or other chronic viral condition score

Immune system total symptom burden

Your form has been submitted

Thank you for filling out the Health Appraisal Questionnaire. Your submission will be reviewed and a report outlining the results and interpretation will be made available at your consultation.

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