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HEALTH
APPRAISAL
NAME:
Date:
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“Nervous” stomach |
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Mentally alert, quick |
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Acid
foods upset |
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Dry
mouth-eyes-nose |
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Extremities cold, clammy |
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Cold
sweats often |
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Pulse
speeds after meal |
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Heart
pounds after retiring |
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Fever
easily raised |
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Keyed
up – fail to calm |
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Perspire easily |
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Vomiting frequently |
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Joint
stiffness after rising |
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Muscle-leg-toe cramps at night |
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Difficulty swallowing |
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Circulation poor, sensitive to cold |
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Eyelids swollen, puffy |
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Constipation, diarrhoea alternating |
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Subject to colds, asthma, bronchitis |
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Indigestion soon after meals |
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Afternoon headaches |
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Heart
palpitations if meals missed or delayed |
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Crave
sweets or coffee in afternoons |
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Get
shaky if hungry |
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Eat
when nervous |
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Abnormal cravings for sweets or snacks |
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Faintness if meals delayed |
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Awaken after a few hours’ sleep, hard to get back to sleep |
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Bruise easily, ‘black and blue’ |
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Swollen ankles, worse at night |
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Hands
and feet go to sleep easily, numbness |
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Sigh
frequently, ‘air-hunger’ |
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Muscle cramps, worse during exercise |
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Tendency to anaemia |
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Aware
of breathing heavily |
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Shortness of breath on exertion |
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Tension under breastbone / tightness worse on exertion |
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Opens
windows in closed rooms |
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Dull
pain in chest or spreading to left arm, worse on exertion |
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Susceptible to colds and fevers |
Open the Word document:
Health Appraisal Questionnaire -
page 2
Questionnaire page 1
Questionnaire page 2
Questionnaire page 3
Questionnaire page 4
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