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HEALTH APPRAISAL

NAME:                                                 

Date:                                                   

 

 

 

Painful periods

 

WOMEN ONLY

 

Vaginal discharge

 

 

Premenstrual tension

 

Heavy / prolonged periods

 

Menopause, hot flushes, etc.

 

 

Easily fatigued

 

Painful breasts

 

Scanty periods

 

 

Depressed before periods

 

Periods too frequent

 

Acne, worse with periods

 

 

Tire too easily

 

MEN ONLY

 

Prostate troubles

 

 

Urination difficult

 

Pain inside legs or heel

 

Restless legs at night

 

 

Night urination frequent

 

Feeling of incomplete bowel emptying

 

Diminished sex drive

 

 

 

 

 

 

 

 

 

 

 

Chronic cough

 

Difficulty breathing

 

Bronchitis (frequent)

 

 

Pain around ribs

 

Coughing up phlegm

 

Infections settle in lungs

 

 

Shortness of breath

 

Coughing up blood

 

Sensitive to smoke

 

 

Chest pain

 

 

 

 

 

 

 

 

Frequent urination

 

Cloudy urine

 

Pain / burning passing urine

 

 

Blood in urine

 

Rarely need to urinate

 

Urinate on cough / sneeze

 

 

Dripping after urination

 

Frequent bladder infections

 

Strong smelling urine

 

 

Difficulty passing urine

 

 

 

 

 

 

 

 

Throat infections

 

Boils / styes

 

Bumpy skin on back of arms

 

 

Poor wound healing

 

Swollen lymph glands

 

Inflamed / bleeding gums

 

 

Slow recovery after cold / flu

 

Catch colds / flu easily

 

 

 

 

 

 

 

 

 

 

Chronic lung congestion

 

Breathe through mouth

 

Hyperactivity

 

 

Post nasal drip

 

Swollen tongue

 

Food sensitivity / allergy

 

Open the Word document:

Health Appraisal Questionnaire - page 4

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