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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 |
|
|
|
Acne,
worse with periods |
|
Tire
too easily |
|
|
|
Prostate troubles |
|
Urination difficult |
|
|
|
Restless legs at night |
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Night
urination frequent |
|
|
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Diminished sex drive |
|
|
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|
|
|
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Chronic cough |
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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 |
|
|
|
|
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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 |
|
|
|
|
|
|
|
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Chronic lung congestion |
|
|
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Hyperactivity |
|
Post
nasal drip |
|
|
|
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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980 3447
What
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