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HEALTH APPRAISAL

NAME:                                                 

Date:                                                   

 

 

 

Dry skin

 

Biliousness

 

Laxative often used

 

 

Skin rashes frequently

 

Greasy foods upset

 

History of gall stones

 

Bitter, metallic taste in mouth in morning

 

Stools light coloured

 

Sneezing attacks

 

Bowel movements painful or difficult

 

Pain between shoulder blades

 

 

 

 

 

 

Lower bowel gas several hours after eating

 

Coated tongue

 

Gas shortly after eating

 

 

Burning stomach sensation relieved by eating

 

Indigestion ½ - 1 hour after eating, or up to 3 – 4 hours

 

Stomach bloating after eating

 

 

 

 

Pulse fast at rest

 

Low blood pressure

 

Hot flushes

 

 

Nervousness

 

Failing memory

 

Headaches

 

 

Can’t gain weight

 

Increased sex drive

 

Dizziness

 

 

Intolerance to heat

 

Splitting headaches

 

Increase in blood pressure

 

 

Highly emotional

 

Decrease sugar tolerance

 

Sugar in urine

 

 

Flush easily

 

 

 

Masculine tendencies (women)

 

 

Night sweats

 

 

 

Low blood pressure

 

 

Inward trembling

 

Intestinal bloating

 

Chronic fatigue

 

 

Heart palpitates

 

Abnormal thirst

 

Weakness dizziness

 

 

Insomnia

 

Weight gain (hips or waist)

 

Tendency to hives

 

 

Impaired hearing

 

Sex desire reduced

 

Arthritic tendencies

 

 

Decrease appetite

 

Tendency to ulcers, colitis

 

Perspiration increase

 

 

Ringing in ears

 

Increased sugar tolerance

 

Crave salt

 

 

Constipation

 

Women: menstrual disorder

 

Brown spots / brown skin

 

 

Mental sluggishness

 

Young girls: lack of menstruation

 

Allergies, asthma

 

 

Headaches on waking

 

 

 

Exhaustion – muscular, nervous

 

 

Slow pulse

 

 

 

Respiratory disorders

 

 

Weight gain

 

 

 

 

Open the Word document:

Health Appraisal Questionnaire - page 3

  • Questionnaire page 1
  • Questionnaire page 2
  • Questionnaire page 3
  • Questionnaire page 4
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