HEALTH APPRAISAL - BRIEF PATIENT FORM
SECTION 1: GASTROINTESTINAL
Section 1.1 Stomach: Hypoacidity *
Never
Occasionally
Moderately / Often
Frequently / Daily
Indigestion
Excessive belching, burping
Bloating or fullness commencing during or shortly after a meal
Sensation of food sitting in stomach for a prolonged period after a meal
Bad breath
Loss of appetite, or nausea
History of anaemia *
Section 1.2 Stomach: Hyperacidity *
Never
Occasionally
Moderately / Often
Frequently / Daily
Stomach pain, burning or aching, 1-4 hours after eating
Feeling hungry just an hour or two after eating
Indigestion or heartburn from spicy or fatty food, citrus, alcohol, or caffeine
Stomach discomfort or pain in response to strong emotions, thoughts, or smell of food
Heartburn aggravated by lying down or bending forward
Antacids, carbonated beverages, milk, cream or food relieve the above symptoms
Constipation
Difficulty or pain when swallowing
Black tarry stools
Vomiting blood or vomitus has appearance of coffee-grounds
Section 1.3 Small Intestine/Pancreas
Never
Occasionally
Moderately / Often
Frequently / Daily
Indigestion, bloating and fullness for several hours after eating
Abdominal cramps or aches
Nausea and/or vomiting
Excessive passage of gas
Diarrhoea (loose, watery or frequent bowel movements)
Constipation (requiring straining, or a hard,dry or small stool)
Alternating constipation and diarrhea
Undigested food in stools
Stools greasy, smelly or stick to toilet bowl
Black tarry stools
Certain foods worsen abdominal symptoms *
Dry flaky skin and dry brittle hair *
Difficulty gaining weight *
Section 1.4 Colon
Never
Occasionally
Moderately / Often
Frequently / Daily
Lower abdominal pain, cramping and/or spasms
Lower abdominal pain relieved by passing gas or stool
Excessive gas and bloating
Certain foods or stress aggravate lower abdominal pain
Diarrhoea (loose, watery or frequent bowel movements)
Constipation (requiring straining, or a hard, dry or small stool)
Alternating diarrhoea and constipation
Sensation of incomplete emptying of bowel
Extremely narrow stools
Mucus or pus in stool
Red blood with bowel movement
Rectal pain or cramps
Anal itching
Section 1.5 Liver/Gall Bladder/Pancreas
Never
Occasionally
Moderately / Often
Frequently / Daily
Upper abdominal pain, or pain under ribs
Bloating or feeling of fullness after eating
Excessive belching or gas
Fatty foods cause indigestion or nausea
Loss of appetite
Nausea and/or vomiting
Unexplained itchy skin
Pale clay-coloured stools
Fatigue, malaise or weakness
Fluid retention, oedema
Easy bruising, or bleeding (e.g. of gums)
Yellowish discolouration of skin or eyes, or dark coloured urine *
Loss or thinning of body hair *
Red skin, particularly on palms *
Dry, flaky skin, or dry hair *
SECTION 2: ENDOCRINE
Section 2.1 Symptoms of underactive thyroid
Never
Occasionally
Moderately / Often
Frequently / Daily
Fatigue, sluggishness
Feeling cold, or intolerance to cold
Constipation (requiring straining, or a hard, dry or small stool)
Puffy face, hands or feet
Low mood
Difficulty concentrating, poor memory
Low libido
Swelling or tightness in front of neck *
Dry skin and hair *
Gaining of weight, or decreased appetite *
Infertility *
Heavier or more frequent menstrual periods *
Section 2.2 Symptoms of overactive thyroid
Never
Occasionally
Moderately / Often
Frequently / Daily
Fatigue, notable weakness in limbs
Feeling hot, or intolerance to heat, sweaty
Diarrhoea (loose, watery or frequent bowel movements)
Palpitations
Nervousness, irritability, restlessness
Tremor
Insomnia
Visual disturbance, problems with eyes, or development of staring gaze
Poor libido
Swelling or tightness in front of neck *
Weight loss, possibly with increased appetite *
Light, infrequent or absent menstrual periods *
Section 2.3 Stress, fatigue and adrenals
Never
Occasionally
Moderately / Often
Frequently / Daily
Feeling stressed, nervous, or tense, or unable to relax
Feeling irritable or oversensitive
Feeling overwhelmed, unable to cope
Low mood, mood swings
Difficulty concentrating or thinking clearly, memory problems
Need coffee, tea, tobacco, sugar or chocolate as pick me ups
Fatigued, tire easily
Find it hard to get up and going in the morning
Difficulty staying awake during day
Insomnia
Palpitations or chest pain
Nausea, dizziness
Change in appetite
SECTION 3: IMMUNE
Section 3.1 Low Immunity
Never
Occasionally
Moderately / Often
Frequently / Daily
Frequent infections in other locations (e.g. bladder, skin)
Diarrhoea (loose, watery or frequent bowel movements)
Ears continuously drain
Nasal congestion or discharge
Sore throat
Cough with mucus
Cold sores
Inflamed or bleeding gums, or swollen, red lips or tongue
Neck, armpit or groin swelling
Frequent colds or flu *
Wounds heal slowly *
Excessive loss of hair *
Section 3.2 Allergy
Never
Occasionally
Moderately / Often
Frequently / Daily
Migraine or non-migraine headache
Sensitivity to light (skin or eyes)
Dark circles under eyes
Swollen eyes, lips, face, or other body parts
Localised or general itching – eyes, ears, throat, nose, skin
Rashes or eczema
Clear watery discharge from nose or eyes
Sneezing, coughing or wheezing
Irritability, fatigue
Certain foods worsen symptoms, or cause palpitations *
SECTION 4: DETOXIFICATION (capacity)
As far as you are aware, do you have a sensitivity or allergy to ...
None
Mild
Moderate
Severe
The preservatives sodium benzoate or potassium benzoate
Tyramine (red wine, cheese, bananas, chocolate)
Caffeine
Chemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odours
Even small amounts of alcohol