Health Appraisal Questionnaire
Hi Friends,

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Loads of Awesome Energy!!!
Dr. Lise’     
Directions  
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 program, 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, click on the button that best describes your symptoms:  
    No/Rarely - You have never experienced the symptom or it is familiar to you but you perceive it as insignificant
    Occasionally - Sypmtom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
    Often - Symptom occurs 2-3 times/ week and/or with a frequency that bothers you enough that you would like to do something about it
    Frequently- Symptom occurs 4 or more time/ week and/or you are aware of it every day or on a monthly/cyclical basis
Some questions require a YES or NO response only:  
Part One - Section A  
Indigestion, food repeats on you after you eat
No / Rarely
Occasionally
Often
Frequently
Excessive burping, belching and/or bloating following meals
No / Rarely
Occasionally
Often
Frequently
Stomach spasms and cramping during or after eating
No / Rarely
Occasionally
Often
Frequently
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
No / Rarely
Occasionally
Often
Frequently
Bad taste in your mouth
No / Rarely
Occasionally
Often
Frequently
Small amounts of food fill you up immediately
No / Rarely
Occasionally
Often
Frequentlyy
Skip meals or eat erratically because you have no appetite
No / Rarely
Occasionally
Often
Frequently
Part One - Section B  
Strong emotions, or the thought or smell of food aggravates your stomach or makes it hurt
No / Rarely
Occasionally
Often
Frequently
Feel hungry an hour or two after eating a good-sized meal
No / Rarely
Occasionally
Often
Frequently
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
No / Rarely
Occasionally
Often
Frequently
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
No / Rarely
Occasionally
Often
Frequently
Burning sensation in the lower part of your chest, especially when lying down or bending forward
No / Rarely
Occasionally
Often
Frequently
Digestive problems that subside with rest and relaxation
No
Yes
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
No / Rarely
Occasionally
Often
Frequently
Feel a sense of nausea when you eat
No / Rarely
Occasionally
Often
Frequently
Difficulty or pain when  swallowing food or beverage
No / Rarely
Occasionally
Often
Frequently
Part One - Section C  
When massaging under your rib cage on your left side, there is pain, tenderness or soreness
No / Rarely
Occasionally
Often
Frequently
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
No / Rarely
Occasionally
Often
Frequently
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
No / Rarely
Occasionally
Often
Frequently
Specific foods/beverages aggravates indigestion
No / Rarely
Occasionally
Often
Frequently
The consistency or form of your stool changes (e.g., from narrow to loose)  within the course of a day
No / Rarely
Occasionally
Often
Frequently
Stool odor is embarrassing
No / Rarely
Occasionally
Often
Frequently
Undigested food in your stool
No / Rarely
Occasionally
Often
Frequently
Three or more large bowel movements daily
No / Rarely
Occasionally
Often
Frequently
Diarrhea (frequent loose, watery stool)
No / Rarely
Occasionally
Often
Frequently
Bowel movement shortly after eating (within 1 hour)
No / Rarely
Occasionally
Often
Frequently
Part One - Section D  
Discomfort, pain or cramps in your colon (lower abdominal area)
No / Rarely
Occasionally
Often
Frequently
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
No / Rarely
Occasionally
Often
Frequently
Generally constipated (or straining during bowel movements)
No / Rarely
Occasionally
Often
Frequently
Stool is small, hard and dry
No / Rarely
Occasionally
Often
Frequently
Pass mucus in your stool
No / Rarely
Occasionally
Often
Frequently
Alternate between constipation and diarrhea
No / Rarely
Occasionally
Often
Frequently
Rectal pain, itching or cramping
No / Rarely
Occasionally
Often
Frequently
No urge to have a bowel movement
No / Rarely
Occasionally
Often
Frequently
An almost continual need to have a bowel movement
No / Rarely
Occasionally
Often
Frequently
Part Two  
When massaging under your rib cage on your right side, there is pain tenderness or soreness
No / Rarely
Occasionally
Often
Frequently
Abdominal pain worsens with deep breathing
No / Rarely
Occasionally
Often
Frequently
Pain at night that may move to your back or right shoulder
No / Rarely
Occasionally
Often
Frequently
Bitter fluid repeats after eating
No / Rarely
Occasionally
Often
Frequently
Feel abdominal discomfort or nausea when eating rich, fatty or fried foods
No / Rarely
Occasionally
Often
Frequently
Throbbing temples and/or dull pain in forehead associated with overeating
No / Rarely
Occasionally
Often
Frequently
Unexplained itchy skin that's worse at night
No / Rarely
Occasionally
Often
Frequently
Stool color alternates from clay colored to normal brown
No / Rarely
Occasionally
Often
Frequently
General feeling of poor health
No / Rarely
Occasionally
Often
Frequently
Aching muscles not due to exercise
No / Rarely
Occasionally
Often
Frequently
Retain fluid and feel swollen around the abdominal area
No / Rarely
Occasionally
Often
Frequently
Reddened skin, especially palms
No / Rarely
Occasionally
Often
Frequently
Very strong body odor
No / Rarely
Occasionally
Often
Frequently
Are you embarrassed by your breath?
No / Rarely
Occasionally
Often
Frequently
Bruise easily
No
Yes
Yellowish cast to eyes
No
Yes
Part Three - Section A  
Feel cold or chilled - hands, feet or all over - for no apparent reason
No / Rarely
Occasionally
Often
Frequently
Your upper eyelids look swollen
No / Rarely
Occasionally
Often
Frequently
Muscles are weak, cramp and/or tremble
No / Rarely
Occasionally
Often
Frequently
Are you forgetful?
No / Rarely
Occasionally
Often
Frequently
Do you feel like your heart beats slowly?
No / Rarely
Occasionally
Often
Frequently
Reaction time seems slowed down
No / Rarely
Occasionally
Often
Frequently
In general, are you disinterested in sex because your desire is low?
No / Rarely
Occasionally
Often
Frequently
Feel slow-moving, sluggish
No / Rarely
Occasionally
Often
Frequently
Constipation
No / Rarely
Occasionally
Often
Frequently
Dryness, discoloration of skin and/or hair
No / Rarely
Occasionally
Often
Frequently
Have you noticed recently that your voice is deepening?
No
Yes
Thick, brittle nails
No
Yes
Weight gain for no apparent reason
No
Yes
Outer third of your eyebrow is thinning or disappearing
No
Yes
Swelling of the neck
No
Yes
Part Three - Section B  
Lingering mild fatigue after exertion or stress
No / Rarely
Occasionally
Often
Frequently
Do you find that you get tired and exhaust easily?
No / Rarely
Occasionally
Often
Frequently
Craving for salty foods
No / Rarely
Occasionally
Often
Frequently
Sensitive to minor changes in weather and surroundings
No / Rarely
Occasionally
Often
Frequently
Dizzy when rising or standing up from a kneeling position
No / Rarely
Occasionally
Often
Frequently
Dark bluish or black circles under your eyes
No / Rarely
Occasionally
Often
Frequently
Have bouts of nausea with or without vomiting
No / Rarely
Occasionally
Often
Frequently
Catch colds or infections easily
No
Yes
Wounds heal slowly
No
Yes
Your body or parts of your body feel tender, sore, sensitive to the touch, hot and/or painful
No / Rarely
Occasionally
Often
Frequently
Feel puffy and swollen all over your body
No / Rarely
Occasionally
Often
Frequently
Skin is gradually tanning without exposure to sun or the ingestion of high levels of carotene-rich foods (e.g., daily carrot juice intake) or supplements
No / Rarely
Occasionally
Often
Frequently
Part Four - Section A  
When you miss meals or go without food for extended periods of time, do you experience any of the following symptoms?
No / Rarely
Occasionally
Often
Frequently
A sense of weakness
No / Rarely
Occasionally
Often
Frequently
A sudden sense of anxiety when you get hungry
No / Rarely
Occasionally
Often
Frequently
Tingling sensation in your hands
No / Rarely
Occasionally
Often
Frequently
A sensation of your heart beating too quickly or forcefully
No / Rarely
Occasionally
Often
Frequently
Shaky, jittery, hands trembling
No / Rarely
Occasionally
Often
Frequently
Sudden profuse sweating and/or your skin feels clammy
No / Rarely
Occasionally
Often
Frequently
Nightmares possibly associated with going to bed on an empty stomach
No / Rarely
Occasionally
Often
Frequently
Wake up at night feeling restless
No / Rarely
Occasionally
Often
Frequently
Agitation, easily upset, nervous
No / Rarely
Occasionally
Often
Frequently
Poor memory, forgetful
No / Rarely
Occasionally
Often
Frequently
Confused or disoriented
No / Rarely
Occasionally
Often
Frequently
Dizzy, faint
No / Rarely
Occasionally
Often
Frequently
Cold or numb
No / Rarely
Occasionally
Often
Frequently
Mild headaches or head pounding
No / Rarely
Occasionally
Often
Frequently
Blurred vision or double vision
No / Rarely
Occasionally
Often
Frequently
Feel clumsy and uncoordinated
No / Rarely
Occasionally
Often
Frequently
Part Four - Section B  
Frequent urination during the day and night
No / Rarely
Occasionally
Often
Frequently
Unusual thirst - feeling like you can't drink enough water
No / Rarely
Occasionally
Often
Frequently
Unusual hunger - eating all the time
No / Rarely
Occasionally
Often
Frequently
Vision blurs
No / Rarely
Occasionally
Often
Frequently
Feel itchy all over
No / Rarely
Occasionally
Often
Frequently
Tingling or numbness in your feet
No / Rarely
Occasionally
Often
Frequently
Sense of drowsiness, lethargy during the day not associated with missing meals or not sleeping
No / Rarely
Occasionally
Often
Frequently
Eating starchy food, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight
No
Yes
Sores heal slowly
No
Yes
Loss of hair on your legs
No
Yes
Part Five - Section A  
Feel Jittery
No / Rarely
Occasionally
Often
Frequently
First effort of the day causes pain, pressure, tightness or heaviness around the chest
No / Rarely
Occasionally
Often
Frequently
Exhaustion with minor exertion
No / Rarely
Occasionally
Often
Frequently
Heavy sweating (no exertion, no hot flashes)
No / Rarely
Occasionally
Often
Frequently
Difficulty catching breath, especially during exercise
No / Rarely
Occasionally
Often
Frequently
Heart pounding, sensation of heart beating too quickly, too slowly or irregularly
No / Rarely
Occasionally
Often
Frequently
Swelling in feet, ankles and/or legs comes and goes for no apparent reason
No / Rarely
Occasionally
Often
Frequently
Part Five - Section B  
Muscle pain at rest
No / Rarely
Occasionally
Often
Frequently
Cramp-like pains in your ankles, calves or legs
No / Rarely
Occasionally
Often
Frequently
Numbness, tingling and prickling sensation in hands and feet
No / Rarely
Occasionally
Often
Frequently
Cold feet and/or toes appear blue
No / Rarely
Occasionally
Often
Frequently
Brief moments of hearing loss
No / Rarely
Occasionally
Often
Frequently
Nausea comes and goes quickly (unrelated to eating)
No / Rarely
Occasionally
Often
Frequently
Feel worse standing: legs get heavy and fatigued
No / Rarely
Occasionally
Often
Frequently
Leg discomfort or fatigue relieved by elevating legs
No / Rarely
Occasionally
Often
Frequently
Fingers and toes get numb in cold weather even when protected
No / Rarely
Occasionally
Often
Frequently
Notice changes in your ability to feel pain or differentiate between sensations of hot or cold
No
Yes
Body hair (on arms, hands, fingers, legs and toes) is thinning or has disappeared
No
Yes
Do you notice a decline in your ability to make decisions, concentrate, focus attention or follow directions?
No
Yes
Part Six - Section A  
Family, friends, work, hobbies or activities you hold dear are no longer of interest
No / Rarely
Occasionally
Often
Frequently
Do you cry?
No / Rarely
Occasionally
Often
Frequently
Does life look entirely hopeless?
No / Rarely
Occasionally
Often
Frequently
Would you describe yourself as feeling miserable and sad, unhappy or blue?
No / Rarely
Occasionally
Often
Frequently
Do you find it hard to make the best of difficult situations?
No / Rarely
Occasionally
Often
Frequently
Sleep problems - too much or too little sleep
No / Rarely
Occasionally
Often
Frequently
Changes in your appetite and weight
No
Yes
Lately you've noticed an inability to think clearly or concentrate
No
Yes
Difficulty making decisions and/or clarifying and achieving your goals
No
Yes
Part Six - Section B  
Does worrying get you down?
No / Rarely
Occasionally
Often
Frequently
Does every little thing get on your nerves and wear you out?
No / Rarely
Occasionally
Often
Frequently
Would you consider yourself a nervous person?
No / Rarely
Occasionally
Often
Frequently
Do you feel easily agitated?
No / Rarely
Occasionally
Often
Frequently
Do you shake and tremble?
No / Rarely
Occasionally
Often
Frequently
Are you keyed up and jittery?
No / Rarely
Occasionally
Often
Frequently
Do you tremble or feel weak when someone shouts at you?
No / Rarely
Occasionally
Often
Frequently
Do you become scared at sudden movements or noises at night?
No / Rarely
Occasionally
Often
Frequently
Do you find yourself sighing a lot?
No / Rarely
Occasionally
Often
Frequently
Are you awakened out of your sleep by frightening dreams?
No / Rarely
Occasionally
Often
Frequently
Do frightening thoughts keep coming back in your mind?
No / Rarely
Occasionally
Often
Frequently
Do you become suddenly scared for no reason?
No / Rarely
Occasionally
Often
Frequently
Do you break out in a cold sweat?
No / Rarely
Occasionally
Often
Frequently
Butterflies in your stomach, nausea and/or diarrhea
No / Rarely
Occasionally
Often
Frequently
Part Six - Section C  
Do you feel pent up and ready to explode?
No / Rarely
Occasionally
Often
Frequently
Are you prone to noisy and emotional outbursts?
No / Rarely
Occasionally
Often
Frequently
Do you do things on impulse?
No / Rarely
Occasionally
Often
Frequently
Are you easily upset or irritated?
No / Rarely
Occasionally
Often
Frequently
Do you go to pieces if you don't control yourself?
No / Rarely
Occasionally
Often
Frequently
Do little annoyances get on your nerves and make you angry?
No / Rarely
Occasionally
Often
Frequently
Does it make you angry to have anyone tell you what to do?
No / Rarely
Occasionally
Often
Frequently
Do you flare up in anger if you can't have what you want right away?
No / Rarely
Occasionally
Often
Frequently
Part Seven  
Eyes water or tear
No / Rarely
Occasionally
Often
Frequently
Mucus discharge from the eyes
No / Rarely
Occasionally
Often
Frequently
Ears ache, itch, feel congested or sore
No / Rarely
Occasionally
Often
Frequently
Discharge from ears
No / Rarely
Occasionally
Often
Frequently
Is your nose continually congested?
No / Rarely
Occasionally
Often
Frequently
Are you prone to loud snoring?
No
Yes
Does your nose run?
No / Rarely
Occasionally
Often
Frequently
Nosebleeds
No
Yes
Hoarse voice
No / Rarely
Occasionally
Often
Frequently
Do you have to clear your throat?
No / Rarely
Occasionally
Often
Frequently
Do you feel a choking lump in your throat?
No / Rarely
Occasionally
Often
Frequently
Do you suffer from severe colds?
No / Rarely
Occasionally
Often
Frequently
Do frequent colds keep you miserable all winter?
No
Yes
Flu symptoms last longer than 5 days
No
Yes
Do infections settle in your lungs?
No
Yes
Chest discomfort or pain
No
Yes
Do you  experience sudden breathing difficulties?
No / Rarely
Occasionally
Often
Frequently
Do you struggle with shortness of breath?
No / Rarely
Occasionally
Often
Frequently
Difficulty exhaling (breathing out)
No / Rarely
Occasionally
Often
Frequently
Breathlessness followed by coughing during exertion, no matter how slight
No / Rarely
Occasionally
Often
Frequently
Inability to breathe comfortably while lying down
No / Rarely
Occasionally
Often
Frequently
Do you cough up lots of phlegm?
No / Rarely
Occasionally
Often
Frequently
Can you hear noisy rattling sounds when breathing in and out?
No / Rarely
Occasionally
Often
Frequently
Are you troubled with coughing?
No / Rarely
Occasionally
Often
Frequently
Do you Wheeze?
No / Rarely
Occasionally
Often
Frequently
Do you have severe soaking sweats at night?
No / Rarely
Occasionally
Often
Frequently
Do your lips and/or nails have a bluish hue?
No / Rarely
Occasionally
Often
Frequently
Are you sleepy during the day?
No / Rarely
Occasionally
Often
Frequently
Do you have difficulty concentrating?
No / Rarely
Occasionally
Often
Frequently
Eyes, ears, nose, throat and lung symptoms seem associated with specific foods like dairy or wheat products
No
Yes
Eyes, ears, nose, throat and lung symptoms are associated with seasonal changes
No
Yes
Part Eight  
Involuntary loss of urine when you cough, lift something or stain during an activity
No / Rarely
Occasionally
Often
Frequently
Mild lower back ache or pain
No / Rarely
Occasionally
Often
Frequently
Abdominal achiness or pain
No / Rarely
Occasionally
Often
Frequently
Pain or burning when urinating
No / Rarely
Occasionally
Often
Frequently
Rarely feel the urge to urinate
No / Rarely
Occasionally
Often
Frequently
Feel the need to urinate less than every two hours during the day or night
No / Rarely
Occasionally
Often
Frequently
Strong smelling urine
No / Rarely
Occasionally
Often
Frequently
Back or leg pains are associated with dripping after urination
No / Rarely
Occasionally
Often
Frequently
Sore or painful genitals
No / Rarely
Occasionally
Often
Frequently
Urine is a rose color
No / Rarely
Occasionally
Often
Frequently
Sudden urge to void causes involuntary loss of urine
No / Rarely
Occasionally
Often
Frequently
Generalized sense of water retention throughout your body
No / Rarely
Occasionally
Often
Frequently
Part Nine - Section A  
Bones throughout your entire body ache, feel tender or sore
No / Rarely
Occasionally
Often
Frequently
Localized bone pain
No / Rarely
Occasionally
Often
Frequently
Hands, feet or throat get tight, spasm or feel numb
No / Rarely
Occasionally
Often
Frequently
Difficulty sitting straight
No / Rarely
Occasionally
Often
Frequently
Upper back pain
No / Rarely
Occasionally
Often
Frequently
Lower back pain
No / Rarely
Occasionally
Often
Frequently
Pain when sitting down or walking
No / Rarely
Occasionally
Often
Frequently
Find yourself limping or favoring one leg
No / Rarely
Occasionally
Often
Frequently
Shins hurt during or after exercise
No / Rarely
Occasionally
Often
Frequently
Part Nine - Section B  
Are you stiff in the morning when you wake up?
No / Rarely
Occasionally
Often
Frequently
Difficulty bending down and picking up clothing or anything from the floor
No / Rarely
Occasionally
Often
Frequently
Joint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)
No / Rarely
Occasionally
Often
Frequently
Joints hurt when moving or when carrying weight
No / Rarely
Occasionally
Often
Frequently
A routine exercise program, like daily walking, causes your knees to swell or hurt
No / Rarely
Occasionally
Often
Frequently
Difficulty opening jars that were previously easy to open
No / Rarely
Occasionally
Often
Frequently
Discomfort, numbness, prickling or tingling sensation, or pain in the neck, shoulder or arm
No / Rarely
Occasionally
Often
Frequently
Intermittent pain or ache on one side of head spreading to cheek, temple, lower jaw, ear, neck and shoulder
No / Rarely
Occasionally
Often
Frequently
Difficulty chewing food or opening mouth
No / Rarely
Occasionally
Often
Frequently
Difficulty standing up from a sitting position
No / Rarely
Occasionally
Often
Frequently
Shooting, aching, tingling, pain down the back of leg
No / Rarely
Occasionally
Often
Frequently
Is it difficult to reach up and get a 5-pound object like a bag of flour from just above your head?
No
Yes
Injure, strain or sprain easily
No
Yes
Part Nine - Section C  
Muscles stiff, sore, tense and/or achy
No / Rarely
Occasionally
Often
Frequently
Burning, throbbing, shooting or stabbing muscle pain
No / Rarely
Occasionally
Often
Frequently
Muscle cramps or spasms (involuntary or after exertion/exercise)
No / Rarely
Occasionally
Often
Frequently
Is muscle pain or stiffness greater in the morning than other times of the day?
No / Rarely
Occasionally
Often
Frequently
Specific points on body feel sore when pressed
No / Rarely
Occasionally
Often
Frequently
Feel unrefreshed upon awakening
No / Rarely
Occasionally
Often
Frequently
Headaches
No / Rarely
Occasionally
Often
Frequently
Pain at the sides of your head or in your face especially when awakening
No / Rarely
Occasionally
Often
Frequently
Your jaw clicks or pops
No / Rarely
Occasionally
Often
Frequently
Muscle twitch or tremor - eyelids, thumb, calf muscle
No / Rarely
Occasionally
Often
Frequently
Irresistible urge to move legs
No / Rarely
Occasionally
Often
Frequently
Legs move during sleep
No / Rarely
Occasionally
Often
Frequently
Unpleasant crawling sensation inside calves when lying down
No / Rarely
Occasionally
Often
Frequently
Hand and wrist numbness or pain (e.g., interferes with writing or with buttoning or unbuttoning your clothes)
No / Rarely
Occasionally
Often
Frequently
Feeling of "pins and needles" in your thumb and first three fingers
No / Rarely
Occasionally
Often
Frequently
Pain in forearm and sometimes in shoulder
No / Rarely
Occasionally
Often
Frequently
Part Ten - Section A  
Head feels heavy
No / Rarely
Occasionally
Often
Frequently
Dizziness
No / Rarely
Occasionally
Often
Frequently
Difficulty bending over, standing up from sitting, rolling over in bed and/or turning your head form side to side
No / Rarely
Occasionally
Often
Frequently
Your hands tremble, ever so slightly, for no apparent reason
No / Rarely
Occasionally
Often
Frequently
You feel like you're wearing heavy weights on your feet when walking
No / Rarely
Occasionally
Often
Frequently
Bump into things, trip, stumble and feel clumsy
No / Rarely
Occasionally
Often
Frequently
Difficulty breathing
No / Rarely
Occasionally
Often
Frequently
Difficulty swallowing
No / Rarely
Occasionally
Often
Frequently
People tell you to speak up because they have trouble hearing you
No / Rarely
Occasionally
Often
Frequently
Speaking and forming words does not feel automatic
No / Rarely
Occasionally
Often
Frequently
Need 10-12 hours of sleep to feel rested
No / Rarely
Occasionally
Often
Frequently
Lack strength (your grip is weak, holding your head or picking your arms up takes effort)
No / Rarely
Occasionally
Often
Frequently
Hands get tired when you write and your handwriting is less legible and smaller than it used to be
No
Yes
Muscles in arms and legs seem softer and smaller
No
Yes
Is your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be?
No
Yes
Do you find yourself moving slower than you used to?
No
Yes
Part Ten - Section B  
Difficulty absorbing new information
No / Rarely
Occasionally
Often
Frequently
Tend to forget things
No / Rarely
Occasionally
Often
Frequently
Trouble thinking or concentrating