Forms: Health Appraisal

Print form below, fill out and bring with you to your office visit:

NAME_____________________________________ DATE___________

CIRCLE the number which best describes the frequency of your symptoms. If you do not know the answer to the question, leave it blank. When you are finished, please add the number of points in each section and enter the number in the Total Point box. The score for YES is the number inside the parenthesis ().

(0) never or rarely
(1) twice a week or less
(2) three to six times a week
(3) daily or several times a day

PART I

Section A
1. Indigestion
0
1
2
3
2. Belching, burping
0
1
2
3
3. Gas immediately following a meal
0
1
2
3
4. Sense of fullness during meals
0
1
2
3
5. Poor appetite, picky eater
0
1
2
3
6. Difficult bowel movements
0
1
2
3
7. Difficulty swallowing
0
1
2
3
8. History of anemia, unresponsive to iron
N
Y(10)
9. Vegetarian (no eggs, dairy)
N
Y(5)
10. Spoon shaped nails
N
Y(3)
11. Unintentional weight loss
N
Y(3)
12. Partial loss of taste or smell N Y(3)
Total Points_________

Section B
1. Indigestion and fullness lasts
2-4 hours after eating
0
1
2
3
2. Pain, tenderness, soreness on
left side under rib cage
0
1
2
3
3. Bloated
0
1
2
3
4. Excessive passage of gas
0
1
2
3
5. Abdominal cramps, aches
0
1
2
3
6. Nausea and/or vomiting
0
1
2
3
7. Specific foods/beverages aggravate indigestion
0
1
2
3
8. Roughage and fiber causes constipation
0
1
2
3
9. Three or more large bowel movements daily
0
1
2
3
10. Alternating constipation and diarrhea
0
1
2
3
11. Undigested food in stool
0
1
2
3
12. Mucus in stool 0 1 2 3
13. Dry, flaky skin, dry brittle hair N Y(3)
14. Difficulty gaining weight N Y(3)
Total Points_________

Section C
1. Stomach pain, burning,
aching 1-4 hours after eating
0
1
2
3
2. Feeling hungry an hour or two after eating
0
1
2
3
3. Stomach discomfort, pain in response to strong emotions, thoughts, smell of food
0
1
2
3
4. Heartburn, especially when lying down,
bending forward
0
1
2
3
5. Heartburn due to spicy and fatty foods,
chocolate, peppers, citrus, alcohol, caffeine
0
1
2
3
6. Difficulty or pain when swallowing
0
1
2
3
7. Chest pain or infections, difficulty breathing
0
1
2
3
8. For relief from carbonated beverages,
cream/milk/food
0
1
2
3
9. Constipation
0
1
2
3
10. Black, tarry stool
0
1
2
3
Total Points_________

Section D
1. Lower abdominal pain,
cramping and/or spasms
0
1
2
3
2. Lower abdominal pain relief
by passing stool or gas
0
1
2
3
3. Raw fruits, vegetables and
stress aggravate bowel pain
0
1
2
3
4. Diarrhea (loose watery stool)
0
1
2
3
5. More than three bowel movements daily
0
1
2
3
6. Excessive gas and bloating
0
1
2
3
7. Painful, difficult, straining
during bowel movements
0
1
2
3
8. Hard, dry or small stool
0
1
2
3
9. Extremely narrow stools
0
1
2
3
10. Alternating diarrhea/constipation
0
1
2
3
11. Mucus, pus in stool
0
1
2
3
12. Feeling that bowels do not empty completely
0
1
2
3
13. Bright red blood following bowel movement
0
1
2
3
14. Anal itching
0
1
2
3
Total Points_________

 

PART II

Section A
1. Moderate to severe pain
under right side or rib cage
0
1
2
3
2. Abdominal pain worsens
with deep breathing
0
1
2
3
3. Regurgitate bitter fluid
0
1
2
3
4. Bloated, full feeling
0
1
2
3
5. Belching, heartburn, gas
0
1
2
3
6. Fatty foods cause indigestion
0
1
2
3
7. Nausea or vomiting
0
1
2
3
8. Feel restless, agitated
0
1
2
3
9. Unexplained itchy skin worse at night
0
1
2
3
10. Stool color alternates from
clay colored to normal brown
0
1
2
3
11. Feeling of poor health
0
1
2
3
12. Fatigue, weakness, exhaustion
0
1
2
3
13. Unable to concentrate, irritable, confused
0
1
2
3
14. Swollen feet and/or legs
0
1
2
3
15. Easy bruising
0
1
2
3
16. Feeling of extreme dryness
0
1
2
3
17. Reddened skin, especially palms
0
1
2
3
18. Dark urine, diminished flow
0
1
2
3
19. Dry, flaky skin, hair
N
Y(3)
20. Yellowish cast to skin, eyes
N
Y(3)
Total Points_________

Section B
1. Fatigue, sluggish
0
1
2
3
2. Feel cold (i.e. hands and feet)
0
1
2
3
3. Difficult, infrequent bowel movements
0
1
2
3
4. Dryness - skin, hair
0
1
2
3
5. Thick, brittle nails
0
1
2
3
6. Outer third of eyebrown thins
0
1
2
3
7. Puffy face, hands and feet
0
1
2
3
8. Swollen upper eyelids
0
1
2
3
9. Eyeballs move involuntarily
0
1
2
3
10. Muscles weak, cramp and/or tremble
0
1
2
3
11. Slow mental processes, forgetfulness
0
1
2
3
12. Slow heart beats
0
1
2
3
13. Loss of appetite
0
1
2
3
14. Abdominal swelling
0
1
2
3
15. Unsteady gait, movements
0
1
2
3
16. Lack of interest in sex
0
1
2
3
17. Premenstrual tension
N
Y(3)
18. Infertility
N
Y(3)
19. Heavy menstrual bleeding
N
Y(3)
20. Gain weight easily
N
Y(10)
21. Swelling of the neck
N
Y(10)
22. Thinning hair on scalp, face and genitals
N
Y(3)
Total Points_________

PART III
1. Progressive, mild fatigue after exertion or stress
0
1
2
3
2. General weakness
0
1
2
3
3. Blurred vision, dizzy when rising
0
1
2
3
4. Depression
0
1
2
3
5. Rapid mood swings
0
1
2
3
6. Irritable, nervous
0
1
2
3
7. Dark circles under the eyes
0
1
2
3
8. Disinterest in food
0
1
2
3
9. Abdominal pain
0
1
2
3
10. Indigestion
0
1
2
3
11. Blotchy skin (white patches)
0
1
2
3
12. Tan skin, no sun
0
1
2
3
13. Black freckles on upper forehead, face, neck
0
1
2
3
14. Craving for salty foods
0
1
2
3
15. Gradual loss of body hair
N
Y(3)
16. Sensitive to subtle changes
in surroundings, weather
N
Y(5)
Total Points_________

 

PART IV

Section A
1. Generalized bone tenderness and achiness
0
1
2
3
2. Localized bone pain
0
1
2
3
3. Bone deformity or swelling
0
1
2
3
4. Shins hurt during or after exercises
0
1
2
3
5. Low back or hip pain
0
1
2
3
6. Limp, walking difficulties
0
1
2
3
7. Crunching or creaking
sounds when move joints
0
1
2
3
8. Hands, feet, throat spasm, feel numb
0
1
2
3
9. Joint pain and stiffness -
especially in spine, hips, knees
0
1
2
3
10. Hearing loss, headaches, ringing in ears
0
1
2
3
11. Established bone loss
N
Y(10)
12. Calcium deposits
N
Y(5)
13. Spinal curvature
N
Y(10)
14. Recent loss of height
N
Y(10)
15. Bow legs
N
Y(5)
16. Stooped posture
N
Y(5)
17. Hump at base of neck
N
Y(5)
18. Unexplained bone fracture
N
Y(10)
19. Tooth loss, gum disease
N
Y(3)
Total Points_________

Section B
1. General muscle ache, pains
0
1
2
3
2. Localized muscle stiffness, tension, pain
0
1
2
3
3. Specific points on body feel
sore when pressed
0
1
2
3
4. Headaches
0
1
2
3
5. Fatigue, tired, sluggish
0
1
2
3
6. Difficulty sleeping
0
1
2
3
7. Feel unrefreshed upon awakening
0
1
2
3
8. Muscle weakness or loss
0
1
2
3
9. Difficulty speaking, swallowing
0
1
2
3
10. Muscle cramps or spasm
0
1
2
3
11. Muscles twitch or tremble -
eyelids, thumb, calf muscle
0
1
2
3
12. Irresistible urge to move legs
0
1
2
3
13. Legs move during sleep
0
1
2
3
14. Numbing, tingling sensation
0
1
2
3
15. Excessive joint mobility
0
1
2
3
16. Unable to fully straighten or
extend loegs and/or arms
0
1
2
3
17. Upper or lower back pain
0
1
2
3
Total Points_________

Section C
1. Joint stiffness, soreness
0
1
2
3
2. Red, swollen painful joints
0
1
2
3
3. Joint stiffness worsens with rest,
improves with moving
0
1
2
3
4. Cracking joints
0
1
2
3
5. Shooting, aching, tingling
pain down the back of leg
0
1
2
3
6. Joint pain involves one or a few joints
0
1
2
3
7. Joints hurt when moving or
when carrying weight
0
1
2
3
8. Limited range of motion
0
1
2
3
9. Difficulty standing up from sitting position
0
1
2
3
10. Joint stiffness improves with rest,
worsens with moving
0
1
2
3
11. Headache
0
1
2
3
12. Difficulty chewing food or opening mouth
0
1
2
3
13. Numbness, prickling, tingling sensation
in the neck, shoulder and arms
0
1
2
3
14. Involuntary muscle spasms
0
1
2
3
15. Deliberate movement with hands is difficult
0
1
2
3
16. Injure, strain, sprain easily
0
1
2
3
17. Discomfort or pain in neck, shoulder or arm
0
1
2
3
18. Knobby overgrowths on the joints
closest to the fingertips
N
Y(5)
19. Double jointed
N
Y(5)
20. One leg shorter than the other
N
Y(5)
Total Points_________