Contact Us
How to Find Us
0425 717 407
Toggle navigation
Home
About
Services
Our Clinic
Blog Posts
Resources
Questionnaires
Books
Cookbooks
Going gluten-free
Green Living
LIfestyle Advice
Testimonials
Courses
Shop
Contact
Health Appraisal Questionnaire
HEALTH APPRAISAL QUESTIONNAIRE
Full name
Date
E-mail address
Key: Tick appropriate box - 1. Never 2. Occasionally 3. Moderately/often 4. Frequently/daily OR Yes or no, where applicable
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity - Indigestion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity - Excessive belching, burping
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity - Bloating or fullness commencing during or shortly after a meal
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity- Sensation of food sitting in stomach for a prolonged period after a meal
Never
Occasionally
Moderately/often
New Option
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity- Bad breath
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity - Loss of appetite, or nausea
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.1 Gastrointestinal System/Stomach: Hypoacidity - History of anaemia
Yes
No
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity- Stomach pain, burning or aching, 1 to 4 hours after eating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Feeling hungry just an hour or two after eating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Indigestion or heartburn from spicy or fatty food, citrus, alcohol or caffeine
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Stomach discomfort or pain in response to strong emotions, thoughts or smell of food
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Heartburn aggravated by lying down or bending forward
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Antacids, carbonated beverages, milk, cream or food relieve the above symptoms
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Constipation
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Difficulty or pain when swallowing
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Black tarry stools
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 1.2 Gastrointestinal System/Stomach: Hyperacidity - Vomiting blood or vomitus has 0 appearance of coffee-grounds
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas -Indigestion, bloating and fullness for several hours after eating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Abdominal cramps or aches
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Nausea and/or vomiting
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Excessive passage of gas
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Diarrhoea (loose, watery or frequent bowel movements)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Constipation (requiring straining, or a hard, dry or small stool)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Alternating constipation and diarrhoea
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Undigested food in stools
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Stools greasy, smelly or stick to toilet bowl
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Black tarry stools
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Certain foods worsen abdominal symptoms
Yes
No
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Dry flaky skin and dry brittle hair
Yes
No
SECTION 1.3 Gastrointestinal System/ Small intestine/Pancreas - Difficulty gaining weight
Yes
No
SECTION 1.4 Gastrointestinal System - Lower abdominal pain, cramping and/or spasms
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Lower abdominal pain relieved by passing gas or stool
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Excessive gas and bloating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Certain foods or stress aggravate lower abdominal pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Diarrhoea (loose, watery or frequent bowel movements)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Constipation (requiring straining, or a hard, dry or small stool)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Alternating diarrhoea and constipation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Sensation of incomplete emptying of bowel
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 1.4 Gastrointestinal System/ Colon - Extremely narrow stools
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Mucus or pus in stool
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Red blood with bowel movement
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon - Rectal pain or cramps
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.4 Gastrointestinal System/ Colon -Anal itching
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas- Upper abdominal pain, or pain under ribs
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Bloating or feeling of fullness after eating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas -Excessive belching or gas
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Fatty foods cause indigestion or nausea
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Loss of appetite
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Nausea and/or vomiting
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Unexplained itchy skin
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Yellowish discolouration of skin or eyes, or dark coloured urine
No
Yes
*SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Pale clay-coloured stools
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Fatigue, malaise or weakness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Fluid retention, oedema
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas- Easy bruising or bleeding (e.g. of gums)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas- Loss or thinning of body hair
No
Yes
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Red skin, particularly on palms
No
Yes
SECTION 1.5 Gastrointestinal System/ Liver/Gall bladder/Pancreas - Dry, flaky skin or dry hair
No
Yes
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Fatigue, sluggishness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Feeling cold, or intolerance to cold
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Swelling or tightness in front of neck
No
Yes
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Constipation (requiring straining, or a hard, dry or small stool)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Dry skin and hair
No
Yes
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Puffy face, hands or feet
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Gaining of weight, or decreased appetite
No
Yes
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Low mood
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Difficulty concentrating, poor memory
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Low libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Infertility
No
Yes
SECTION 2.1 Endocrine System/ Symptoms of underactive thyroid - Heavier or more frequent menstrual periods
No
Yes
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- Fatigue, notable weakness in limbs
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Feeling hot, or intolerance to heat, sweaty
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Swelling or tightness in front of neck
No
Yes
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Diarrhoea (loose, watery or frequent bowel movements)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Weight loss, possibly with increased appetite
No
Yes
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Palpitations
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Nervousness, irritability, restlessness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Tremor
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Visual disturbance, problems with eyes, or development of staring gaze
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid- - Poor libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.2 Endocrine System/ Symptoms of overactive thyroid-- Light, infrequent or absent menstrual periods
No
Yes
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Feeling stressed, nervous, tense or unable to relax
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Feeling irritable or oversensitive
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Feeling overwhelmed, unable to cope
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Low mood, mood swings
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Difficulty concentrating or thinking clearly, memory problems
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Need coffee, tea, tobacco, sugar or chocolate as pick me ups
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Fatigued, tire easily
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Find it hard to get up and going in the morning
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Difficulty staying awake during day
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Insomnia
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Palpitations or chest pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals- Nausea, dizziness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 2.3 Endocrine System/ Stress, fatigue and adrenals - Change in appetite
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity - Frequent colds or flu
No
Yes
SECTION 3.1 Immune/ Low immunity- Frequent infections in other locations (e.g. bladder, skin)
No
Yes
SECTION 3.1 Immune/ Low immunity- Diarrhoea
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity- Ears continuously drain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity- Nasal congestion or discharge
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity - Sore throat
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity - Cough with mucus
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity - Cold sores
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity- Inflamed or bleeding gums, or swollen, red lips or tongue
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.1 Immune/ Low immunity- Wounds heal slowly
No
Yes
SECTION 3.1 Immune/ Low immunity - Excessive loss of hair
No
Yes
*SECTION 3.1 Immune/ Low immunity - Neck, armpit or groin swelling
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy- Migraine or non-migraine headache
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy- Sensitivity to light (skin or eyes)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy - Dark circles under eyes
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy- Swollen eyes, lips, face or other body parts
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy - Localised or general itching – eyes, ears, 0 throat, nose, skin
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy- Rashes or eczema
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy - Clear watery discharge from nose or eyes
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy- Sneezing, coughing or wheezing
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy - Irritability, fatigue
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 3.2 Immune / Allergy - Certain foods worsen symptoms or cause palpitations
No
Yes
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Excessive fatigue
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Prolonged recovery after exercise
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Low exercise tolerance, shortness of breath with exertion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Difficulty concentrating, poor memory
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Yellowing of eyes or skin
No
Yes
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Pale eyelids, lips, gums, nails
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Red sore tongue
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance- Sores in corner of mouth
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Easy bruising or bleeding
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.1 Cardiovascular/ Healthy red blood cell maintenance - Dizziness, spots before eyes or ringing in ears
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.2 Cardiovascular/ Healthy blood pressure maintenance - Headaches
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.2 Cardiovascular/ Healthy blood pressure maintenance- Nosebleeds
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.2 Cardiovascular/ Healthy blood pressure maintenance- Redness in face
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.2 Cardiovascular/ Healthy blood pressure maintenance - Ringing in ears or blurred vision
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.2 Cardiovascular/ Healthy blood pressure maintenance - History of high blood pressure
No
Yes
SECTION 4.3 Cardiovascular/ Heart - Palpitations
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Dizziness
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.3 Cardiovascular/ Heart - Pain or heaviness in central chest
Never
Occasionally
Moderately/often
Frequently/daily
*/SECTION 4.3 Cardiovascular/ Heart - Heartburn, pain or heavy crushing sensation that moves to neck, jaw, left shoulder or arm
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.3 Cardiovascular/ Heart - Pallor or sweating with chest discomfort or with unusual indigestion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Fatigue easily, poor exercise tolerance
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Shortness of breath with exertion
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.3 Cardiovascular/ Heart - Shortness of breath lying flat in bed, or 8 sudden shortness of breath in the middle of the night
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Wheezing or dry cough
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Veins on neck are prominent
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - Swelling in feet, ankles or legs
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.3 Cardiovascular/ Heart - History of high blood cholesterol
No
Yes
SECTION 4.4 Cardiovascular / Circulatory system- Poor circulation in extremities: coldness or numbness, tingling or pricking sensations in hands or feet, discolouration in fingers or toes
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.4 Cardiovascular / Circulatory system - Ulcers on feet or legs
No
Yes
SECTION 4.4 Cardiovascular / Circulatory system - Muscle pain in calves or thighs with walking
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 4.4 Cardiovascular / Circulatory system - Difficulty concentrating, poor memory
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.4 Cardiovascular / Circulatory system - Faints or falls with unknown cause
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.4 Cardiovascular / Circulatory system - Brief periods of difficulty speaking, swallowing, or understanding speech or written word
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 4.4 Cardiovascular / Circulatory system- Brief periods of loss of whole or part of vision, double vision, impaired coordination, or areas of numbness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia - When you miss a meal, do you feel...Fatigue and weakness, or feeling shaky
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia - When you miss a meal, do you feel...Mild headache
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia - When you miss a meal, do you feel...Sweating or palpitations
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia - When you miss a meal, do you feel...Feeling light-headed or faint
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia- When you miss a meal, do you feel...Difficulty concentrating, poor memory, confusion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.1 Glucose Tolerance/ Symptoms of hypoglycaemia- When you miss a meal, do you feel...Agitation, irritability
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Excessive, frequent urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia- Increased thirst and appetite
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Blurred vision, failing eyesight
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia- Fatigue, drowsiness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Profuse sweating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Dizziness when standing from sitting position
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Unintentional weight loss or excessive weight gain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia- Recurrent or persistent infections (e.g. bladder, skin)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Ulcers or sores on legs or feet
No
Yes
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Slow wound healing
No
Yes
SECTION 5.2 Glucose Tolerance/ Symptoms of hyperglycaemia - Diagnosis of diabetes
No
Yes
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Fluid retention throughout body
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Lower back pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Excessive urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Excessive urination during night1-2)
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Burning with urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Frequent urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Urgency of urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Bloody, cloudy or darkened urine, or strong-smelling urine
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Incontinence
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Infrequent urination
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder -Grey cast to skin
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - Severe one-sided lower back or groin pain associated with restlessness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.1 Genitourinary System and reproductive hormones/ Kidney/Bladder - History of kidney stones
No
Yes
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Difficulty starting urine flow, or poor flow of urine
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance -Sense of bladder fullness, incomplete emptying, or needing to strain with small amounts of urine passed
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Dripping after urination
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Ejaculation causes pain
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Blood in semen
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Low libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Difficulty attaining or maintaining an erection
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Premature ejaculation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Low energy level or stamina
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Infertility, low sperm count or poor motility
No
Yes
*SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance -Inflammation of penis, or unusual discharge from penis
No
Yes
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance -Genital or groin rash, irritation, itchiness or infection
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Painful testicle(s)
No
Yes
*SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Testicles uneven in size, texture or hardness
No
Yes
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Both testicles appear smaller
No
Yes
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Loss or thinning of body or facial hair, or slow hair growth
No
Yes
SECTION 6.2 Genitourinary System and reproductive hormones/ Prostate/Male hormone balance - Development of breasts or nipple tenderness
No
Yes
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS - Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Insomnia
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Abdominal bloating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Breast tenderness, swelling or lumps
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Feeling depressed, teary or sensitive
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Feeling anxious, irritable or easily angered
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS - Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Diarrhoea or constipation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Headaches or migraines
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Food cravings or binge eating
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS - Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Back pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Fluid retention or weight gain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS - Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Clumsiness
Never
Occasionally
Moderately/often
Frequently/daily
*?SECTION 6.3 Genitourinary System and reproductive hormones/ Symptoms of PMS- Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 months: Feeling aggressive or feeling suicidal
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Irregular intervals between periods
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Long period cycles, greater than 32 days
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months:Short period cycles, less than 24 days
No
Yes
*SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Vaginal bleeding between periods
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Painful periods – lower abdomen or back
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.4 Genitourinary System and reproductive hormones/ Symptoms of menopause: Pain with periods is worsening
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Painful intercourse during menstruation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Pelvic and/or rectal pressure around menstruation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months:Constipation or diarrhoea with menstruation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Nausea and/or vomiting with menstruation
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Light blood flow
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Heavy blood flow or flooding
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Passage of large or profuse blood clots
No
Yes
SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Prolonged duration of bleeding
No
Yes
*SECTION 6.4 Genitourinary System and reproductive hormones/ Menstrual irregularities - Symptoms experienced in the past 3 months: Absence of menstrual flow for more than 5 months
No
Yes
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Irregular menstrual cycle and/or changes in menstrual flow (heavier or lighter)
No
Yes
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Dry skin, hair or vagina
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause-Low libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Mood swings, irritability, depression, nervousness, anxiety
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Hot flushes
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Night sweats
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause-Headaches or dizziness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Painful intercourse
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Insomnia
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause- Difficulty concentrating, poor memory or confusion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause-Thinning of armpit and pubic hair, or increased hair growth on upper lip
No
Yes
SECTION 6.5 Genitourinary System and reproductive hormones/ Symptoms of menopause-Breasts reducing in size and starting to sag
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Vaginal dryness or pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Milk production (not nursing) or engorged breasts
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Painful intercourse
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Low libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Excessive libido
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Acne and/or oily skin
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Excess facial hair
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Breasts shrinking
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Thinning body hair
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Infertility
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Miscarriage 40 years ago
No
Yes
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Vaginal discharge: excessive, smelly, or coloured
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Burning or itching of external genitalia
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Vaginal bleeding after intercourse, or between periods
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Lower abdominal or back pain
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Breast lumps, or a change in breast size or shape
No
Yes
*SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems -Nipple discharge or change in appearance of nipple
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 6.6 Genitourinary System and reproductive hormones/ Other female sexual and hormonal problems - Swelling under armpit
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Generalised bone tenderness or achiness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.1 Musculoskeletal/Bone - Localised bone pain
Never
Occasionally
Moderately/often
Frequently/daily
S*ECTION 7.1 Musculoskeletal/Bone - Bone deformity or swelling
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Shins hurt during or after exercise
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.1 Musculoskeletal/Bone - Low back or hip pain
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.1 Musculoskeletal/Bone - Walking difficulties or a limp
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 7.1 Musculoskeletal/Bone - Hearing loss, headaches, ringing in ears
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Diagnosis of osteoporosis
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Abnormal spinal curvature
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Recent loss of height
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Bowed legs
No
Yes
SECTION 7.1 Musculoskeletal/Bone - Stooped posture or hump at base of neck
No
Yes
*SECTION 7.1 Musculoskeletal/Bone - Unexplained bone fracture
No
Yes
SECTION 7.2 Musculoskeletal/Muscle - Muscle aches and pains
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Muscle stiffness, tension
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Specific body points are tender to touch
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Headaches
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Fatigue
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Difficulty sleeping
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Muscle cramps or spasms
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Muscles twitch or tremble
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Restless legs
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.2 Musculoskeletal/Muscle - Upper or lower back pain
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 7.2 Musculoskeletal/Muscle - Muscle weakness
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 7.2 Musculoskeletal/Muscle - Muscle loss and wasting
No
Yes
SECTION 7.3 Musculoskeletal/Connective tissue - Tender, red, swollen and stiff joints
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Dry mouth, dry, painful eyes
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Creaking (noisy) joints
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Limp
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 7.3 Musculoskeletal/Connective tissue - Shooting, aching, tingling pain down back of leg
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Joint pain involves more than one joint
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Limited range of motion
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Difficulty standing up from seated position
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Impaired mobility or function
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Difficulty chewing or opening mouth
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 7.3 Musculoskeletal/Connective tissue - Numbness, prickling, tingling sensation in neck, shoulders or arms
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 7.3 Musculoskeletal/Connective tissue - Injure, strain, sprain easily
No
Yes
SECTION 7.3 Musculoskeletal/Connective tissue - Red, painless skin lumps on elbows, knees, toes
No
Yes
SECTION 7.3 Musculoskeletal/Connective tissue - Knobbly joints
No
Yes
*SECTION 7.3 Musculoskeletal/Connective tissue - Muscle wasting
No
Yes
SECTION 8.1 Brain and Nervous System/Neurological -Headache
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Light-headedness, fainting
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.1 Brain and Nervous System/Neurological -Ringing or buzzing in ears
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.1 Brain and Nervous System/Neurological -Trembling hands
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Weakness
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Numbness, pins and needles, or tingling in limbs
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Unsteady on feet
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.1 Brain and Nervous System/Neurological -Easily fatigued
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Poor hand coordination
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Convulsions, seizures or funny turns
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.1 Brain and Nervous System/Neurological -Difficulty concentrating, confused, poor memory
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.1 Brain and Nervous System/Neurological -Clumsy
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Drooping eyelid(s)
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Impaired hearing, eyesight, sense of touch, smell or taste
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Slow or slurred speech
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 8.1 Brain and Nervous System/Neurological -Incontinence
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Divorce
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Separation from partner
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Marriage
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Death of close family member or friend
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Loss of work, retirement or starting a new job
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Bankruptcy, or a major change in finances
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Moving house
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Major personal injury or illness
No
Yes
SECTION 8.2 Brain and Nervous System/ Stress history -In past 2 years have you experienced Violations of the law
No
Yes
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Have an overactive mind or worry excessively
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Live or work in a stressful environment
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Suffer from constant pain or discomfort
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Eat chocolate or drink caffeine in the evenings
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Have difficulty falling asleep or staying asleep
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.3 – Brain and Nervous System/ Symptoms of insomnia -Do you...Eat after 8 pm
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Find it difficult to keep still, or are fidgety
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Have a short attention span
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Find it difficult to relax
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Experience mental confusion or sluggishness
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Have or had learning difficulties
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 8.4 – Brain and Nervous System/ Normal, healthy learning and concentration -Do you...Have food allergies
No
Yes
SECTION 9 – Respiratory System - Shortness of breath, increased effort to breathe
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Wheezing
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Shallow breathing
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Cough, dry or moist
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Thick yellow, greenish or brown sputum
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 9 – Respiratory System -Blood in sputum
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 9 – Respiratory System -Frothy sputum
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Noisy rattling sounds when breathing
Never
Occasionally
Moderately/often
Frequently/daily
*SECTION 9 – Respiratory System -Pain in chest
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Bad breath or sputum smells offensive
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Loud snoring
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 9 – Respiratory System -Colds always “go to the chest”
No
Yes
*SECTION 9 – Respiratory System -Bluish nails or lips
Never
Occasionally
Moderately/often
Frequently/daily
SECTION 10– Hair, Skin and Nails -Acne
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Psoriasis
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Eczema/dermatitis
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Warts
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails - Tinea
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Dandruff
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Rashes
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Areas of increased pigmentation
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Areas of decreased pigmentation
None
Mild
Moderate
Severe
*SECTION 10– Hair, Skin and Nails -Unusual or changing moles
No
Yes
SECTION 10– Hair, Skin and Nails -Areas of unexplained redness
None
Mild
Moderate
Severe
*SECTION 10– Hair, Skin and Nails -Undiagnosed skin lumps/bumps
No
Yes
SECTION 10– Hair, Skin and Nails -Discoloured nails
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Pitted nails
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Weak/brittle nails
None
Mild
Moderate
Severe
SECTION 10– Hair, Skin and Nails -Thickened nails
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...The preservatives sodium benzoate or potassium benzoate
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Tyramine (red wine, cheese, bananas, chocolate)
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Caffeine
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Chemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odours
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to..Even small amounts of alcohol.
None
Mild
Moderate
Severe
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Do you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents?
No
Yes
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Alcohol (number of drinks per week)
0
1-7
8-14
15+
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Coffee or other caffeinated drinks (number per day)
0
1-2
3-4
5+
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Smoking (number per day)?
0
1-8
9-19
20+
SECTION 11– Detoxification Capacity - if you answered yes to question above, then what do you smoke?
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...If not currently smoking, have you quit smoking in the last year?
No
Yes
SECTION 11– Detoxification Capacity- As far as you are aware, do you have a sensitivity or allergy to...Recreational drugs?
No
Yes
SECTION 11– Detoxification Capacity - if you answered yes to question above, then what type of drug?
SECTION 11– Detoxification Capacity - What is your blood type?
SECTION 12.1 General Health History/Patient health history-Frequency of exercise (days per week)
6-7
3-5
1-2
0
SECTION 12.1 General Health History/Patient health history - Vegetarian or vegan
No
Yes
SECTION 12.1 General Health History/Patient health history - Age >50 years
No
Yes
SECTION 12.1 General Health History/Patient health history - Planning to have a baby in the next 3 to 6 months
No
Yes
SECTION 12.1 General Health History/Patient health history - Pregnant or breastfeeding
No
Yes
SECTION 12.2 General Health History/Weight management -Do you diet often?
No
Yes
SECTION 12.2 General Health History/Weight management -Are you unhappy with your weight?
No
Yes
*SECTION 12.3 General Health History/High risk symptoms - Unexplained weight loss
No
Yes
*SECTION 12.3 General Health History/High risk symptoms - night sweats
None
Mild
Moderate
Severe
*SECTION 12.3 General Health History/High risk symptoms - Fevers
None
Mild
Moderate
Severe
*SECTION 12.3 General Health History/High risk symptoms - Lumps (e.g. breast, armpit, skin)
No
Yes
*SECTION 12.3 General Health History/High risk symptoms - Reduced appetite
None
Mild
Moderate
Severe
*SECTION 12.3 General Health History/High risk symptoms - Severe fatigue
None
Mild
Moderate
Severe
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Asthma medications/inhalers
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Anti-diabetics/insulin
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Steroids (e.g. cortisone)
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Anti-inflammatories/Aspirin
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Paracetamol
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? High blood pressure
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Heart
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Thyroid
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Antihistamines
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Antiulcer medications, antacids
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Antibiotics/Antifungals
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Antidepressants
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Relaxants/Sleeping tablets
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Antipsychotics
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Relaxants/Sleeping tablets
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Hormones/Oral contraceptives
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Chemotherapy
No
Yes
SECTION 12.4 General Health History - Which of the following types of medications have you taken in the last 6 months? Anti-cholesterol medication
No
Yes
Thank you for taking the time to complete this questionnaire.
Submit
Δ