Electronic Health Appraisal Questionnaire Electronic Health Appraisal Questionnaire Name Client EmailDatePreviousNextSECTION 1 - GASTROINTESTINAL SECTION 1.1 – Stomach: Hypoacidity How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Indigestion Never Occasionally Moderately / Often Frequently / DailyExcessive belching, burping Never Occasionally Moderately / Often Frequently / DailyBloating or fullness commencing during or shortly after a meal Never Occasionally Moderately / Often Frequently / DailySensation of food sitting in stomach for a prolonged period after a meal Never Occasionally Moderately / Often Frequently / DailyBad breath Never Occasionally Moderately / Often Frequently / DailyLoss of appetite, or nausea Never Occasionally Moderately / Often Frequently / DailyHistory of anaemia No YesSection 1.1 - Total PreviousNextSECTION 1.2 – Stomach: Hyperacidity How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Stomach pain, burning or aching, 1 to 4 hours after eating Never Occasionally Moderately / Often Frequently / DailyFeeling hungry just an hour or two after eating Never Occasionally Moderately / Often Frequently / DailyIndigestion or heartburn from spicy or fatty food, citrus, alcohol or caffeine Never Occasionally Moderately / Often Frequently / DailyStomach discomfort or pain in response to strong emotions, thoughts or smell of food Never Occasionally Moderately / Often Frequently / DailyHeartburn aggravated by lying down or bending forward Never Occasionally Moderately / Often Frequently / DailyAntacids, carbonated beverages, milk, cream or food relieve the above symptoms Never Occasionally Moderately / Often Frequently / DailyConstipation Never Occasionally Moderately / Often Frequently / DailyDifficulty or pain when swallowing Never Occasionally Moderately / Often Frequently / DailyBlack tarry stools Never Occasionally Moderately / Often Frequently / DailyVomiting blood or vomitus has appearance of coffee-grounds Never Occasionally Moderately / Often Frequently / DailySection 1.2 - TotalPreviousNextSECTION 1.3 – Small intestine/Pancreas: How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Indigestion, bloating and fullness for several hours after eating Never Occasionally Moderately / Often Frequently / DailyAbdominal cramps or aches Never Occasionally Moderately / Often Frequently / DailyNausea and/or vomiting Never Occasionally Moderately / Often Frequently / DailyExcessive passage of gas Never Occasionally Moderately / Often Frequently / DailyDiarrhoea (loose, watery or frequent bowel movements) Never Occasionally Moderately / Often Frequently / DailyConstipation (requiring straining, or a hard, dry or small stool) Never Occasionally Moderately / Often Frequently / DailyAlternating constipation and diarrhoea Never Occasionally Moderately / Often Frequently / DailyUndigested food in stools Never Occasionally Moderately / Often Frequently / DailyStools greasy, smelly or stick to toilet bow Never Occasionally Moderately / Often Frequently / DailyBlack tarry stools Never Occasionally Moderately / Often Frequently / DailyCertain foods worsen abdominal symptoms No YesDry flaky skin and dry brittle hair No YesDifficulty gaining weight No YesSection 1.3 - Total PreviousNextSECTION 1.4 – Colon: How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Lower abdominal pain, cramping and/or spasms Never Occasionally Moderately / Often Frequently / DailyLower abdominal pain relieved by passing gas or stool Never Occasionally Moderately / Often Frequently / DailyExcessive gas and bloating Never Occasionally Moderately / Often Frequently / DailyCertain foods or stress aggravate lower abdominal pain Never Occasionally Moderately / Often Frequently / DailyDiarrhoea (loose, watery or frequent bowel movements) Never Occasionally Moderately / Often Frequently / DailyConstipation (requiring straining, or a hard, dry or small stool) Never Occasionally Moderately / Often Frequently / DailyAlternating diarrhoea and constipation Never Occasionally Moderately / Often Frequently / DailySensation of incomplete emptying of bowel Never Occasionally Moderately / Often Frequently / DailyExtremely narrow stools Never Occasionally Moderately / Often Frequently / DailyMucus or pus in stool Never Occasionally Moderately / Often Frequently / DailyRed blood with bowel movement Never Occasionally Moderately / Often Frequently / DailyRectal pain or cramps Never Occasionally Moderately / Often Frequently / DailyAnal itching Never Occasionally Moderately / Often Frequently / DailySection 1.4 - Total PreviousNextSECTION 1.5 – Liver/Gall bladder/Pancreas: How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Upper abdominal pain, or pain under ribs Never Occasionally Moderately / Often Frequently / DailyBloating or feeling of fullness after eating Never Occasionally Moderately / Often Frequently / DailyExcessive belching or gas Never Occasionally Moderately / Often Frequently / DailyFatty foods cause indigestion or nausea Never Occasionally Moderately / Often Frequently / DailyLoss of appetite Never Occasionally Moderately / Often Frequently / DailyNausea and/or vomiting Never Occasionally Moderately / Often Frequently / DailyUnexplained itchy skin Never Occasionally Moderately / Often Frequently / DailyYellowish discolouration of skin or eyes, or dark coloured urine No YesPale clay-coloured stools Never Occasionally Moderately / Often Frequently / DailyFatigue, malaise or weakness Never Occasionally Moderately / Often Frequently / DailyFluid retention, oedema Never Occasionally Moderately / Often Frequently / DailyEasy bruising or bleeding (e.g. of gums) Never Occasionally Moderately / Often Frequently / DailyLoss or thinning of body hair No YesRed skin, particularly on palms No YesDry, flaky skin or dry hair No YesSection 1.5 - Total Save & ResumePreviousNextSECTION 2 - ENDOCRINE SECTION 2.1 –Symptoms of underactive thyroid How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Fatigue, sluggishness Never Occasionally Moderately / Often Frequently / DailyFeeling cold, or intolerance to cold Never Occasionally Moderately / Often Frequently / DailySwelling or tightness in front of neck No YesConstipation (requiring straining, or a hard, dry or small stool) Never Occasionally Moderately / Often Frequently / DailyDry skin and hair No YesPuffy face, hands or feet Never Occasionally Moderately / Often Frequently / DailyGaining of weight, or decreased appetite No YesLow mood Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, poor memory Never Occasionally Moderately / Often Frequently / DailyLow libido Never Occasionally Moderately / Often Frequently / DailyInfertility No YesHeavier or more frequent menstrual periods No YesSection 2.1 - Total PreviousNextSECTION 2.2 –Symptoms of overactive thyroid How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Fatigue, notable weakness in limbs Never Occasionally Moderately / Often Frequently / DailyFeeling hot, or intolerance to heat, sweaty Never Occasionally Moderately / Often Frequently / DailySwelling or tightness in front of neck No YesDiarrhoea (loose, watery or frequent bowel movements) Never Occasionally Moderately / Often Frequently / DailyWeight loss, possibly with increased appetite No YesPalpitations Never Occasionally Moderately / Often Frequently / DailyNervousness, irritability, restlessness Never Occasionally Moderately / Often Frequently / DailyTremor Never Occasionally Moderately / Often Frequently / Daily Insomnia Never Occasionally Moderately / Often Frequently / DailyVisual disturbance, problems with eyes, or development of staring gaze Never Occasionally Moderately / Often Frequently / DailyPoor libido Never Occasionally Moderately / Often Frequently / DailyLight, infrequent or absent menstrual periods No YesSection 2.2 Total PreviousNextSECTION 2.3 –Stress, fatigue and adrenals How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Feeling stressed, nervous, tense or unable to relax Never Occasionally Moderately / Often Frequently / DailyFeeling irritable or oversensitive Never Occasionally Moderately / Often Frequently / DailyFeeling overwhelmed, unable to cope Never Occasionally Moderately / Often Frequently / DailyLow mood, mood swings Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating or thinking clearly, memory problems Never Occasionally Moderately / Often Frequently / DailyNeed coffee, tea, tobacco, sugar or chocolate as pick me ups Never Occasionally Moderately / Often Frequently / DailyFatigued, tire easily Never Occasionally Moderately / Often Frequently / DailyFind it hard to get up and going in the morning Never Occasionally Moderately / Often Frequently / DailyDifficulty staying awake during day Never Occasionally Moderately / Often Frequently / DailyPalpitations or chest pain Never Occasionally Moderately / Often Frequently / DailyNausea, dizziness Never Occasionally Moderately / Often Frequently / DailyChange in appetite Never Occasionally Moderately / Often Frequently / DailySection 2.3 - Total PreviousNextSECTION 3 - IMMUNE SECTION 3.1 – Low immunity How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Frequent colds or flu No YesFrequent infections in other locations (e.g. bladder, skin) No YesDiarrhoea Never Occasionally Moderately / Often Frequently / DailyEars continuously drain Never Occasionally Moderately / Often Frequently / DailyNasal congestion or discharge Never Occasionally Moderately / Often Frequently / DailySore throat Never Occasionally Moderately / Often Frequently / DailyCough with mucus Never Occasionally Moderately / Often Frequently / DailyCold sores Never Occasionally Moderately / Often Frequently / DailyInflamed or bleeding gums, or swollen, red lips or tongue Never Occasionally Moderately / Often Frequently / DailyWounds heal slowly No YesExcessive loss of hair No YesNeck, armpit or groin swelling Never Occasionally Moderately / Often Frequently / DailySection 3.1 - Total PreviousNextSECTION 3.2 – Allergy How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Migraine or non-migraine headache Never Occasionally Moderately / Often Frequently / DailySensitivity to light (skin or eyes) Never Occasionally Moderately / Often Frequently / DailyDark circles under eyes Never Occasionally Moderately / Often Frequently / DailySwollen eyes, lips, face or other body parts Never Occasionally Moderately / Often Frequently / DailyLocalised or general itching – eyes, ears, throat, nose, skin Never Occasionally Moderately / Often Frequently / DailyRashes or eczema Never Occasionally Moderately / Often Frequently / DailyClear watery discharge from nose or eyes Never Occasionally Moderately / Often Frequently / DailySneezing, coughing or wheezing Never Occasionally Moderately / Often Frequently / DailyIrritability, fatigue Never Occasionally Moderately / Often Frequently / DailyCertain foods worsen symptoms or cause palpitations Never Occasionally Moderately / Often Frequently / DailySection 3.2 - Total Save & ResumePreviousNextSECTION 4 - CARDIOVASCULAR SECTION 4.1 – Healthy red blood cell maintenance How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Excessive fatigue Never Occasionally Moderately / Often Frequently / DailyProlonged recovery after exercise Never Occasionally Moderately / Often Frequently / DailyLow exercise tolerance, shortness of breath with exertion Never Occasionally Moderately / Often Frequently / DailyDizziness, spots before eyes or ringing in ears Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, poor memory Never Occasionally Moderately / Often Frequently / DailyYellowing of eyes or skin No YesPale eyelids, lips, gums, nails Never Occasionally Moderately / Often Frequently / DailyRed sore tongue Never Occasionally Moderately / Often Frequently / DailySores in corner of mouth Never Occasionally Moderately / Often Frequently / DailyEasy bruising or bleeding Never Occasionally Moderately / Often Frequently / DailySection 4.1 - Total PreviousNextSECTION 4.2 – Healthy blood pressure maintenance How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Headaches Never Occasionally Moderately / Often Frequently / DailyNosebleeds Never Occasionally Moderately / Often Frequently / DailyRedness in face Never Occasionally Moderately / Often Frequently / DailyRinging in ears or blurred vision Never Occasionally Moderately / Often Frequently / DailyHistory of high blood pressure No YesSection 4.2 - Total PreviousNextSECTION 4.3 – Heart How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Palpitations Never Occasionally Moderately / Often Frequently / DailyDizziness Never Occasionally Moderately / Often Frequently / DailyPain or heaviness in central chest Never Occasionally Moderately / Often Frequently / DailyHeartburn, pain or heavy crushing sensation that moves to neck, jaw, left shoulder or arm Never Occasionally Moderately / Often Frequently / DailyPallor or sweating with chest discomfort or with unusual indigestion, left shoulder or arm Never Occasionally Moderately / Often Frequently / DailyFatigue easily, poor exercise tolerance Never Occasionally Moderately / Often Frequently / DailyShortness of breath with exertion Never Occasionally Moderately / Often Frequently / DailyShortness of breath lying flat in bed, or sudden shortness of breath in the middle of the night Never Occasionally Moderately / Often Frequently / DailyWheezing or dry cough Never Occasionally Moderately / Often Frequently / DailyVeins on neck are prominent Never Occasionally Moderately / Often Frequently / DailySwelling in feet, ankles or legs Never Occasionally Moderately / Often Frequently / DailyHistory of high blood cholesterol No YesSection 4.3 - Total PreviousNextSECTION 4.4 – Circulatory system How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)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 / DailyUlcers on feet or legs No YesMuscle pain in calves or thighs with walking Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, poor memory Never Occasionally Moderately / Often Frequently / DailyFaints or falls with unknown cause Never Occasionally Moderately / Often Frequently / DailyBrief periods of difficulty speaking, swallowing, or understanding speech or written word Never Occasionally Moderately / Often Frequently / DailyBrief periods of loss of whole or part of vision, double vision, impaired coordination, or areas of numbness Never Occasionally Moderately / Often Frequently / DailySection 4.4 - Total PreviousNextSECTION 5 - GLUCOSE TOLERANCE SECTION 5.1 – Symptoms of Hypoglycaemia When you miss a meal, do you feel... (Please only choose one option for the most accurate result.)Fatigue and weakness, or feeling shaky Never Occasionally Moderately / Often Frequently / DailyMild headache Never Occasionally Moderately / Often Frequently / DailySweating or palpitations Never Occasionally Moderately / Often Frequently / DailyFeeling light-headed or faint Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, poor memory, confusion Never Occasionally Moderately / Often Frequently / DailyAgitation, irritability Never Occasionally Moderately / Often Frequently / DailySection 5.1 - Total PreviousNextSECTION 5.2 – Symptoms of hyperglycaemia How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Excessive, frequent urination Never Occasionally Moderately / Often Frequently / DailyIncreased thirst and appetite Never Occasionally Moderately / Often Frequently / DailyBlurred vision, failing eyesight Never Occasionally Moderately / Often Frequently / DailyFatigue, drowsiness Never Occasionally Moderately / Often Frequently / DailyProfuse sweating Never Occasionally Moderately / Often Frequently / DailyDizziness when standing from sitting position Never Occasionally Moderately / Often Frequently / DailyUnintentional weight loss or excessive weight gain Never Occasionally Moderately / Often Frequently / DailyRecurrent or persistent infections (e.g. bladder, skin) Never Occasionally Moderately / Often Frequently / DailyUlcers or sores on legs or feet no yesSlow wound healing no yesDiagnosis of diabetes no yesSection 5.2 - Total Save & ResumePreviousNextSECTION 6- GENITOURINARY SYSTEM AND REPRODUCTIVE HORMONES SECTION 6.1 – Kidney/Bladder How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Fluid retention throughout body Never Occasionally Moderately / Often Frequently / DailyLower back pain Never Occasionally Moderately / Often Frequently / DailyExcessive urination Never Occasionally Moderately / Often Frequently / DailyExcessive urination during night Never Occasionally Moderately / Often Frequently / DailyBurning with urination Never Occasionally Moderately / Often Frequently / DailyFrequent urination Never Occasionally Moderately / Often Frequently / DailyUrgency of urination Never Occasionally Moderately / Often Frequently / DailyBloody, cloudy or darkened urine, or strong-smelling urine Never Occasionally Moderately / Often Frequently / DailyIncontinence Never Occasionally Moderately / Often Frequently / DailyInfrequent urination Never Occasionally Moderately / Often Frequently / DailyGrey cast to skin Never Occasionally Moderately / Often Frequently / DailySevere one-sided lower back or groin pain associated with restlessness Never Occasionally Moderately / Often Frequently / DailyHistory of kidney stones no yesSection 6.1 - Total PreviousNextSECTION 6.2 – Prostate/Male hormone balance How often do you experience the below symptoms? (Men only to answer this section. Please only choose one option for the most accurate result.)Difficulty starting urine flow, or poor flow of urine Never Occasionally Moderately / Often Frequently / DailySense of bladder fullness, incomplete emptying, or needing to strain with small amounts of urine passed Never Occasionally Moderately / Often Frequently / DailyDripping after urination Never Occasionally Moderately / Often Frequently / DailyEjaculation causes pain Never Occasionally Moderately / Often Frequently / DailyBlood in semen Never Occasionally Moderately / Often Frequently / DailyLow libido Never Occasionally Moderately / Often Frequently / DailyDifficulty attaining or maintaining an erection Never Occasionally Moderately / Often Frequently / DailyPremature ejaculationn Never Occasionally Moderately / Often Frequently / DailyLow energy level or stamina Never Occasionally Moderately / Often Frequently / DailyInfertility, low sperm count or poor motility No YesInflammation of penis, or unusual discharge from penis No YesGenital or groin rash, irritation, itchiness or infection Never Occasionally Moderately / Often Frequently / DailyPainful testicle(s) Never Occasionally Moderately / Often Frequently / DailyTesticles uneven in size, texture or hardness No YesBoth testicles appear smaller No YesLoss or thinning of body or facial hair, or slow hair growth No YesDevelopment of breasts or nipple tenderness No YesSection 6.2 - TotalSave ProgressPreviousNextSECTION 6.3 – Symptoms of PMS How often have you experienced the symptoms below in the 3 to 14 days prior to menstruation, in the last 3 months? (Women only to answer this section. Please only choose one option for the most accurate result.)Insomnia Never Occasionally Moderately / Often Frequently / DailyAbdominal bloating Never Occasionally Moderately / Often Frequently / DailyBreast tenderness, swelling or lumps Never Occasionally Moderately / Often Frequently / DailyFeeling depressed, teary or sensitive Never Occasionally Moderately / Often Frequently / DailyFeeling anxious, irritable or easily angered Never Occasionally Moderately / Often Frequently / DailyDiarrhoea or constipation Never Occasionally Moderately / Often Frequently / DailyHeadaches or migraines Never Occasionally Moderately / Often Frequently / DailyFood cravings or binge eating Never Occasionally Moderately / Often Frequently / DailyBack pain Never Occasionally Moderately / Often Frequently / DailyFluid retention or weight gain Never Occasionally Moderately / Often Frequently / DailyClumsiness Never Occasionally Moderately / Often Frequently / DailyFeeling aggressive or feeling suicidal Never Occasionally Moderately / Often Frequently / DailySection 6.3 - Total PreviousNextSECTION 6.4 – Menstrual irregularities How often have you experience the below symptoms in the past 3 months? (Women only to answer this section. Please only choose one option for the most accurate result.)Irregular intervals between periods No YesLong period cycles, greater than 32 days No YesShort period cycles, less than 24 day No YesVaginal bleeding between periods No YesPainful periods – lower abdomen or back Never Occasionally Moderately / Often Frequently / DailyPain with periods is worsening No YesPainful intercourse during menstruation Never Occasionally Moderately / Often Frequently / DailyPelvic and/or rectal pressure around menstruation Never Occasionally Moderately / Often Frequently / DailyConstipation or diarrhoea with menstruation Never Occasionally Moderately / Often Frequently / DailyNausea and/or vomiting with menstruation Never Occasionally Moderately / Often Frequently / DailyLight blood flow No YesHeavy blood flow or flooding No YesPassage of large or profuse blood clots No YesProlonged duration of bleeding No YesProlonged duration of bleeding - Number of Days: Absence of menstrual flow for more than 5 months No YesSection 6.4 - Total PreviousNextSECTION 6.5 – Symptoms of menopause How often do you experience the below symptoms? (Women only to answer this section. Please only choose one option for the most accurate result.)Irregular menstrual cycle and/or changes in menstrual flow (heavier or lighter) No YesDry skin, hair or vagina Never Occasionally Moderately / Often Frequently / DailyLow libido Never Occasionally Moderately / Often Frequently / DailyMood swings, irritability, depression, nervousness, anxiety Never Occasionally Moderately / Often Frequently / DailyHot flushes Never Occasionally Moderately / Often Frequently / DailyNight sweats Never Occasionally Moderately / Often Frequently / DailyHeadaches or dizziness Never Occasionally Moderately / Often Frequently / DailyPainful intercourse Never Occasionally Moderately / Often Frequently / DailyInsomnia Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, poor memory or confusion Never Occasionally Moderately / Often Frequently / DailyThinning of armpit and pubic hair, or increased hair growth on upper lip No YesBreasts reducing in size and starting to sag No YesSection 6.5 - Total PreviousNextSECTION 6.6 – Other female sexual and hormonal problems How often do you experience the below symptoms? (Women only to answer this section. Please only choose one option for the most accurate result.)Vaginal dryness or pain Never Occasionally Moderately / Often Frequently / DailyPainful intercourse Never Occasionally Moderately / Often Frequently / DailyMilk production (not nursing) or engorged breasts Never Occasionally Moderately / Often Frequently / DailyLow libido Never Occasionally Moderately / Often Frequently / DailyExcessive libido Never Occasionally Moderately / Often Frequently / DailyAcne and/or oily skin Never Occasionally Moderately / Often Frequently / DailyExcess facial hair No YesBreasts shrinking No YesThinning body hair No YesInfertility No YesMiscarriage No YesVaginal discharge: excessive, smelly, or coloured Never Occasionally Moderately / Often Frequently / DailyBurning or itching of external genitalia Never Occasionally Moderately / Often Frequently / DailyVaginal bleeding after intercourse, or between periods Never Occasionally Moderately / Often Frequently / DailyLower abdominal or back pain Never Occasionally Moderately / Often Frequently / DailyBreast lumps, or a change in breast size or shape No Yes Nipple discharge or change in appearance of nipple Never Occasionally Moderately / Often Frequently / DailySwelling under armpit No Yes Section 6.6 - Total Save & ResumePreviousNextSECTION 7 - MUSCULOSKELETAL SECTION 7.1 – Bone Do you experience the below symptoms? (Please only choose one option for the most accurate result.)Generalised bone tenderness or achiness Never Occasionally Moderately / Often Frequently / DailyLocalised bone pain Never Occasionally Moderately / Often Frequently / DailyBone deformity or swelling No YesShins hurt during or after exercise Never Occasionally Moderately / Often Frequently / DailyLow back or hip pain Never Occasionally Moderately / Often Frequently / DailyWalking difficulties or a limp Never Occasionally Moderately / Often Frequently / DailyHearing loss, headaches, ringing in ears No YesDiagnosis of osteoporosis No YesAbnormal spinal curvature No YesRecent loss of height No YesBowed legs No YesStooped posture or hump at base of neck No YesUnexplained bone fracture No YesSection 7.1 - Total PreviousNextSECTION 7.2 – Muscle How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Muscle aches and pains Never Occasionally Moderately / Often Frequently / DailyMuscle stiffness, tension Never Occasionally Moderately / Often Frequently / DailySpecific body points are tender to touch Never Occasionally Moderately / Often Frequently / DailyHeadaches Never Occasionally Moderately / Often Frequently / DailyFatigue Never Occasionally Moderately / Often Frequently / DailyDifficulty sleeping Never Occasionally Moderately / Often Frequently / DailyMuscle cramps or spasms Never Occasionally Moderately / Often Frequently / DailyMuscles twitch or tremble Never Occasionally Moderately / Often Frequently / DailyRestless legs Never Occasionally Moderately / Often Frequently / DailyUpper or lower back pain Never Occasionally Moderately / Often Frequently / DailyMuscle weakness Never Occasionally Moderately / Often Frequently / DailyMuscle loss and wasting No YesSection 7.2 - Total PreviousNextSECTION 7.3 – Connective tissue How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Tender, red, swollen and stiff joints Never Occasionally Moderately / Often Frequently / DailyDry mouth, dry, painful eyes Never Occasionally Moderately / Often Frequently / DailyCreaking (noisy) joints Never Occasionally Moderately / Often Frequently / DailyLimp Never Occasionally Moderately / Often Frequently / DailyShooting, aching, tingling pain down back of leg Never Occasionally Moderately / Often Frequently / DailyJoint pain involves more than one joint Never Occasionally Moderately / Often Frequently / DailyLimited range of motion Never Occasionally Moderately / Often Frequently / DailyDifficulty standing up from seated position Never Occasionally Moderately / Often Frequently / DailyImpaired mobility or function Never Occasionally Moderately / Often Frequently / DailyDifficulty chewing or opening mouth Never Occasionally Moderately / Often Frequently / DailyNumbness, prickling, tingling sensation in neck, shoulders or arms Never Occasionally Moderately / Often Frequently / DailyInjure, strain, sprain easily No YesRed, painless skin lumps on elbows, knees, toes No YesKnobbly joints No YesMuscle wasting No YesSection 7.3 - Total PreviousNextSECTION 8 - BRAIN AND NERVOUS SYSTEM SECTION 8.1 – Neurological How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Headache Never Occasionally Moderately / Often Frequently / DailyLight-headedness, fainting Never Occasionally Moderately / Often Frequently / DailyRinging or buzzing in ears Never Occasionally Moderately / Often Frequently / DailyTrembling hands Never Occasionally Moderately / Often Frequently / DailyWeakness Never Occasionally Moderately / Often Frequently / DailyNumbness, pins and needles, or tingling in limbs Never Occasionally Moderately / Often Frequently / DailyUnsteady on feet Never Occasionally Moderately / Often Frequently / DailyEasily fatigued Never Occasionally Moderately / Often Frequently / DailyPoor hand coordination Never Occasionally Moderately / Often Frequently / DailyConvulsions, seizures or funny turns Never Occasionally Moderately / Often Frequently / DailyDifficulty concentrating, confused, poor memory Never Occasionally Moderately / Often Frequently / DailyClumsy Never Occasionally Moderately / Often Frequently / DailyDrooping eyelid(s) Never Occasionally Moderately / Often Frequently / DailyImpaired hearing, eyesight, sense of touch, smell or taste Never Occasionally Moderately / Often Frequently / DailySlow or slurred speech Never Occasionally Moderately / Often Frequently / DailyIncontinence Never Occasionally Moderately / Often Frequently / DailySection 8.1 - Total PreviousNextSECTION 8.2 – Stress history In past 2 years have you experienced... (Please only choose one option for the most accurate result.)Divorce No Yes Separation from partner No Yes Marriage No Yes Death of close family member or friend No Yes Loss of work, retirement or starting a new job No Yes Bankruptcy, or a major change in finances No Yes Moving house No Yes Major personal injury or illness No Yes Violations of the law No Yes Section 8.2 - Total PreviousNextSECTION 8.3 – Symptoms of insomnia Do you... (Please only choose one option for the most accurate result.)Have an overactive mind or worry excessively Never Occasionally Moderately / Often Frequently / DailyLive or work in a stressful environment Never Occasionally Moderately / Often Frequently / DailySuffer from constant pain or discomfort Never Occasionally Moderately / Often Frequently / DailyEat chocolate or drink caffeine in the evenings Never Occasionally Moderately / Often Frequently / DailyHave difficulty falling asleep or staying asleep Never Occasionally Moderately / Often Frequently / DailyEat after 8 pm Never Occasionally Moderately / Often Frequently / DailySection 8.3 - Total PreviousNextSECTION 8.4 – Normal, healthy learning and concentration Do you... (Please only choose one option for the most accurate result.)Find it difficult to keep still, or are fidgety Never Occasionally Moderately / Often Frequently / DailyHave a short attention span Never Occasionally Moderately / Often Frequently / DailyFind it difficult to relax Never Occasionally Moderately / Often Frequently / DailyExperience mental confusion or sluggishness Never Occasionally Moderately / Often Frequently / DailyHave or had learning difficulties No Yes Have food allergies No Yes Section 8.4 - Total Save & ResumePreviousNextSECTION 9 - RESPIRATORY SYSTEM How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Shortness of breath, increased effort to breathe Never Occasionally Moderately / Often Frequently / DailyWheezing Never Occasionally Moderately / Often Frequently / DailyShallow breathing Never Occasionally Moderately / Often Frequently / DailyCough, dry or moist Never Occasionally Moderately / Often Frequently / DailyThick yellow, greenish or brown sputum Never Occasionally Moderately / Often Frequently / DailyBlood in sputum Never Occasionally Moderately / Often Frequently / DailyFrothy sputum Never Occasionally Moderately / Often Frequently / DailyNoisy rattling sounds when breathing Never Occasionally Moderately / Often Frequently / DailyPain in chest Never Occasionally Moderately / Often Frequently / DailyBad breath or sputum smells offensive Never Occasionally Moderately / Often Frequently / DailyLoud snoring Never Occasionally Moderately / Often Frequently / DailyColds always “go to the chest” No YesBluish nails or lips Never Occasionally Moderately / Often Frequently / DailySection 9 - Total PreviousNextSECTION 10 - HAIR, SKIN AND NAILS How often do you experience the below symptoms? (Please only choose one option for the most accurate result.)Acne None Mild Moderate SeverePsoriasis None Mild Moderate SevereEczema/dermatitis None Mild Moderate SevereWarts None Mild Moderate SevereTinea None Mild Moderate SevereDandruff None Mild Moderate SevereRashes None Mild Moderate SevereAreas of increased pigmentation None Mild Moderate SevereAreas of decreased pigmentation None Mild Moderate SevereUnusual or changing moles No YesAreas of unexplained redness None Mild Moderate SevereUndiagnosed skin lumps/bumps No YesDiscoloured nails None Mild Moderate SeverePitted nails None Mild Moderate SevereWeak/brittle nails None Mild Moderate SevereThickened nails None Mild Moderate SevereSection 10 - Total PreviousNextSECTION 11 - DETOXIFICATION (CAPACITY) As far as you are aware, do you have a sensitivity or allergy to... (Please only choose one option for the most accurate result.)The preservatives sodium benzoate or potassium benzoate None Mild Moderate SevereTyramine (red wine, cheese, bananas, chocolate) None Mild Moderate SevereCaffeine None Mild Moderate SevereChemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odours None Mild Moderate SevereEven small amounts of alcohol None Mild Moderate SevereDo you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents? No YesAlcohol (number of drinks per week) 0 1-7 8-14 15+Coffee or other caffeinated drinks (number per day) 0 1-2 3-4 5+Smoking (number per day)? 0 1-9 9-19 20+If you smoke, what type of cigarettes do you smoke? If not currently smoking, have you quit smoking in the last year? No YesDo you use recreational drugs? No YesIf you use recreational drugs, what type do you use? What is your blood type? Section 11 - Total Save & ResumePreviousNextSECTION 12 - GENERAL HEALTH HISTORY SECTION 12.1 – Patient health history (Please only choose one option for the most accurate result.)Frequency of exercise (days per week) 6-7 3-5 1-2 0Vegetarian or vegan No YesAge >50 years No YesPlanning to have a baby in the next 3 to 6 months No YesPregnant or breastfeeding No YesSection 12.1 - Total PreviousNextSECTION 12.2 – Weight management (Please only choose one option for the most accurate result.)Do you diet often? No YesAre you unhappy with your weight? No YesSection 12.2 - Total PreviousNextSECTION 12.3 – High risk symptoms (Please only choose one option for the most accurate result.)Unexplained weight loss No YesNight Sweats None Mild Moderate SevereFevers None Mild Moderate SevereLumps (e.g. breast, armpit, skin) No YesReduced appetite None Mild Moderate SevereSevere fatigue None Mild Moderate SevereSection 12.3 - Total PreviousNextSECTION 12.4 Which of the following types of medications have you taken in the last 6 months? (Please only choose one option for the most accurate result.)Asthma medications/inhalers No YesAnti-diabetics/insulin No YesSteroids (e.g. cortisone) No YesAnti-inflammatories/Aspirin No YesParacetamol No YesHigh blood pressure No YesHeart No YesThyroid No YesAntihistamines No YesAntiulcer medications, antacids No YesAntibiotics/Antifungals No YesAntidepressants No YesAntipsychotics No YesRelaxants/Sleeping tablets No YesHormones/Oral contraceptives No YesChemotherapy No YesAny other medications? No YesIf yes, what type of medications have you taken? List the nutritional or herbal supplements you are currently taking:List any major health problems in past, surgery, etc.:List your major health concerns at present:Family History - Do you have a family history of diabetes, cardiovascular disease, cancer or any other major illness?Save & Resume Previous Submit Form
