Health Assessment Form
Health Coach Indy
Full Name
*
First Name
Last Name
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Any of the following medications you are taking:
Antacids (Turns, etc.)
Cholesterol Medication
Hormones
Antibiotic/Antifungal
Cortisone Anti-inflammatories
Laxatives
Antidepressants
Diuretics
Lithium
Antidiabetic/Insulin
Heart Medications
Oral Contraceptives
Aspirin/Tylenol
High Blood Pressure Medications
Radiation
Chemotherapy
Relaxants/Sleeping Pills
Recreational Drugs
Thyroid
Ulcer Medications
Are you eating or drinking the following:
Alcohol (beer, wine)
Candy
Carbonated Beverages
Cigarettes
Coffee
Distilled Water
Luncheon Meals
Fluoridated/Chlorinated Water
Margarine
At fast food restaurants regularly
Refined Sugars
Non-Herbal Teas
Chew Tobacco
Vitamins & Minerals
Fried Foods
Milk Products
Refined (White) Flour Products
Artificial Sweeteners
If the following is true:
Gluten Sensitivity
Chinese food or salad bars make you ill?
Celiac's Disease
Do you get hives or headaches from drinking wine?
If the following is true:
Diet often
Salt food without tasting
Exercise less than 3 times weekly
Are exposed to chemicals at work
Are under excessive stress
Are exposed to cigarette smoke
Directions for the following questions:
Never Mild = Occurs once a month Moderate = Occurs several time a month Severe = Aware of it almost constantly
Category I - Section A
Rows
Never
Mild
Moderate
Severe
Bad breath, halitosis
Loss of taste for high protein foods
Burning (“acid”) or nervous stomach
Gas shortly after eating
Indigestion 30 to 60 mins after eating
Diffucult digesting fruits & vegetables
Acid or spicy foods upset stomach.
Category I - Section B
Rows
Never/No
Mild
Moderate
Severe
Lower bowel gas and/or bloating several hours after eating
Feet burn
Whites of eyes (sclera) yellow
Dry skin, itchy feet and/or skin
Brown spots or bronzing of skin
Bitter metallic taste in mouth
Blurred vision
Headache over eyes
Feel nauseous, queasy or gas easily
Color of stools light brown or yellow
Greasy or high fat foods cause distress
Pain between shoulder blades
Dark circles under eyes
“Acid” breath
History of gallbladder attacks or gallstones
Gallbladder removed
Appetite reduced
Category I - Section C
Rows
Never
Mild
Moderate
Severe
Coated tongue or “fuzzy” debris on tongue
Pass large amounts of foul smelling gas
Irritable bowl or mucous colitis
Constipation, diarrhea alternating or stools alternate from soft to watery
Bowel movements painful or difficult, constipation and/or laxatives used
Burning or itching anus
Category II
Rows
Never
Mild
Moderate
Severe
Head congestion sinus fullness
Sneezing attacks
Dreaming, nightmare-like bad dreams
Milk products and/or wheat products cause distress
Eyes and nose watery
Eyes swollen and puffy
Pulse speeds after meals and/or heart pounds after retiring
Category III - Section A
Rows
Never
Mild
Moderate
Severe
Crave sweets or coffee in afternoon or mid morning
Hungry between meals or excessive appetite
Overeating sweets upsets stomach
Eat when nervous
Irritable before meals
Get “shaky” or light-headed if meals delayed
Fatigue, eating relieves
Heart palpitates if meals are missed or delayed
Awaken a few hours after sleep, hard to get back to sleep
Category III - Section B
Rows
Never/No
Mild
Moderate
Severe
Muscle soreness after moderate exercise
Vulnerability to insect bites (fleas and mosquitoes)
Loss of muscle tone or “heaviness” in arms or legs
Enlarged heart and/or heart failure
Worrier, feel insecure and/or highly emotional
Pulse slow/below 65 or irregular pulse
Category IV - Section A
Rows
Never
Mild
Moderate
Severe
Sex drive increased
“Splitting” type headaches
Memory failing
Tolerance for sugar reduced
Category IV - Section B
Rows
Never
Mild
Moderate
Severe
Sex drive reduced or absent
Abnormal thirst
Weight gain around hips or waist
Tendency to ulcers or colitis
Increased ability to eat sugar without symptoms
Menstrual disorders (women)
Lack of menstruation (young girls)
Category IV - Section C
Rows
Never
Mild
Moderate
Severe
Difficulty gaining weight, even if large appetite
Heart palpitations
Nervous, emotional, and/or can't work under pressure
Insomnia
Inward trembling
Night sweats
Fast pulse at rest
Intolerant to high temperatures
Easily flushed
Category IV - Section D
Rows
Never
Mild
Moderate
Severe
Difficulty losing weight
Reduced initiative and/or mental sluggishness
Easily fatigued, sleepy during the day
Sensitive to cold, poor circulation (cold hands and feet)
Dry or scaly skin
“Ringing” in ears/noise in head
Hearing impaired
Constipation
Excessive falling hair and/or coarse hair
Headaches when awaken/wear off during the day
Category IV - Section E
Rows
Never
Mild
Moderate
Severe
Blood pressure increased
Headaches
Hot flashes
Hair growth on face or body (females)
Masculine tendencies (females)
Category IV - Section F
Rows
Never
Mild
Moderate
Severe
Blood pressure low
Crave salt
Chronic fatigue/get drowsy
Afternoon yawning
Weakness/dizziness
Weakness after colds/slow recovery
Circulation poor
Muscular and nervous exhaustions
Subject to colds, asthma, bronchitis (respiratory disorders)
Allergies and/or hives
Difficulty maintaining manipulative correction
Arthritic tendencies
Nails weak, ridged
Perspire easily
Slow starter in morning
Afternoon headaches
Category V - Section A
Rows
Never/No
Mild
Moderate
Severe
Frequent skin rashes and/or hives
Muscle-leg-toe cramping at rest or while sleeping
Fever easily raised/fevers common
Crave chocolate
Feet have bad odor
Hoarseness frequent
Difficulty swallowing
Joint stiffness after rising
Vomiting frequent
Tendency to anemia
"Whites” of eyes (sclera) blue
“Lump” in throat
Dry mouth-eyes-nose
White spots on finger nails
Cuts heal slowly and/or scar easily
Reduced or “lost” sense of taste and/or smell
Susceptible to colds, fevers, and/or infections
Strong light irritates eyes
Noises in head or ringing in ears
Burning sensations in mouth
Numbness in hands and feet (extremities “go to sleep")
Intolerant to monosodium glutamate (MSG)
Cannot recall dreams
Nose bleeds frequent
Bruise easily, “black and blue” spots
Muscle cramps. Worse with exercise
Category VI
Rows
Never
Mild
Moderate
Severe
Aware of heavy and/or irregular breathing
Discomfort in high altitudes
“Air hunger"/sigh frequently
Swollen ankles/worse at night
Shortness of breath with exertion
Dull pain in chest and/or pain radiating into left arm, worse on exertion
Category VII - Female Only
Rows
Never/No
Mild
Moderate
Severe
Premenstrual tension
Painful menses (cramping, etc.)
Menstruation excessive or prolonged
Painful/tender breasts
Menstruate too frequently
Acne, worse at menses
Depressed feelings before menstruation
Vaginal discharge
Menses scanty or missed
Hysterectomy/ovaries removed
Menopausal hot flashes
Depression
Category VIII - Male Only
Rows
Never
Mild
Moderate
Severe
Prostate trouble
Urination difficulty or dribbling
Night urination frequent
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night
Tire easily/avoid activity
Reduced sex drive
Depression
Migrating aches and pains
List any vitamins/supplements you are currently taking:
Do you have any medication allergies?
Yes
No
Do you use any kind of tobacco or have you ever used them?
Yes
No
Submit
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