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HEALTH APPRAISAL

NAME:                                                 

Date:                                                   

 

 

 

“Nervous” stomach

 

Mentally alert, quick

 

Acid foods upset

 

 

Dry mouth-eyes-nose

 

Extremities cold, clammy

 

Cold sweats often

 

 

Pulse speeds after meal

 

Heart pounds after retiring

 

Fever easily raised

 

 

Keyed up – fail to calm

 

 

 

 

 

 

 

 

Are your symptoms made worse by emotional stress?

 

 

               

 

 

 

 

Perspire easily

 

Vomiting frequently

 

Joint stiffness after rising

 

 

Muscle-leg-toe cramps at night

 

Difficulty swallowing

 

Circulation poor, sensitive to cold

 

 

Eyelids swollen, puffy

 

Constipation, diarrhoea alternating

 

Subject to colds, asthma, bronchitis

 

 

Indigestion soon after meals

 

Digestion rapid

 

 

 

 

 

 

Are your symptoms made worse by physical stress?

 

 

               

 

 

 

 

Afternoon headaches

 

Heart palpitations if meals missed or delayed

 

Crave sweets or coffee in afternoons

 

 

Get shaky if hungry

 

Eat when nervous

 

Abnormal cravings for sweets or snacks

 

 

Faintness if meals delayed

 

Awaken after a few hours’ sleep, hard to get back to sleep

 

 

 

               

 

 

 

 

Bruise easily, ‘black and blue’

 

Swollen ankles, worse at night

 

Hands and feet go to sleep easily, numbness

 

 

Sigh frequently, ‘air-hunger’

 

Muscle cramps, worse during exercise

 

Tendency to anaemia

 

 

Aware of breathing heavily

 

Shortness of breath on exertion

 

Tension under breastbone / tightness worse on exertion

 

 

Opens windows in closed rooms

 

Dull pain in chest or spreading to left arm, worse on exertion

 

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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