nelsonhealingcenter.org - Health Appraisal Questionnaire

HEALTH APPRAISAL QUESTIONNAIRE
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DIRECTION

This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

For each question, select the number that best describes your symptoms:
O = No or Rarely-You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or less)
1 = Occasionally-Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
4 = Often-Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently-Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis

Some questions require a YES or NO response: O= No 8 = YES
PART I

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Indigestion, food repeats on you after you eat
2. Excessive burping, belching and/or bloating following meal
3. Stomach spasms and cramping during or after eating
4. A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
5. Bad taste in your mouth
6. Small amounts of food fill you up immediately
7. Skip meals or eat erratically because you have no appetite

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Strong emotions or the thought or smell of food aggravates your stomach or makes it hurt
2. Feel hungry an hour or two after eating a good-sized meal
3. Stomach pain, burning and/or aching over a period of 1-4 hours after eating
4. Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
5. Burning sensation in the lower part of your chest, especially when lying down or bending forward
6. Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
7. Feel a sense of nausea when you eat
8. Difficulty or pain when swallowing food or beverage

9. Digestive problems that subside with rest and relaxation

SECTION C

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. When massaging under your rib cage on your left side, there is pain, tenderness or soreness
2. Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
3. Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
4. Specific foods/beverages aggravate indigestion
5. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
6. Stool odor is embarrassing
7. Undigested Food in your stool
8. Three or more large bowel movements daily
9. Diarrhea (frequent loose, watery stool)
10. Bowel movement shortly after eating (within 1 hour)

SECTION D

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Discomfort, pain or cramps in your colon (lower abdominal area)
2. Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
3. Generally constipated (or straining during bowel movements)
4. Stool is small, hard and dry
5. Pass mucus in your stool
6. Alternate between constipation and diarrhea
7. Rectal pain, itching or cramping
8. No urge to have a bowel movement
9. An almost continual need to have a bowel movement

PART II

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. When massaging under your rib cage on your right side, there is pain, tenderness, or soreness
2. Abdominal pain worsens with deep breathing
3. Pain at night that may move to your back or right shoulder
4. Bitter fluid repeats after eating
5. Feel abdominal discomfort or nausea when eating rich, fatty, or fried foods
6. Throbbing temples and/or dull pain in the forehead associated with overeating
7. Unexplained itchy skin that's worse at night
8. Stool color alternates from clay colored to the normal brown
9. General feeling of poor health
10. Aching muscles not due to exercise
11. Retain fluid and feel swollen around the abdominal area
12. Reddened skin, especially palms
13. Very strong body odor
14. Are you embarrassed by your breath?
15. Bruise easily
16. Yellowish cast to eyes

PART III

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Feel cold or chilled-hands, feet, or all over for no apparent reason
2. Your upper eyelids look swollen
3. Muscles are weak, cramp, and/or tremble
4. Are you forgetful?
5. Do you feel like your heart beats slowly?
6. Reaction time seems slowed down
7. In general, are you disinterested in sex because your desire is low?
8. Feel slow-moving, sluggish
9. Constipation

Rows	0 (No)	8 (Yes)
10. Dryness, discoloration of skin and/or hair
11. Have you noticed recently that your voice is deepening?
12. Thick, brittle nails
13. Weight gain for no apparent reason
14. Outer third of your eyebrow is thinning or disappearing
15. Swelling of the neck

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Lingering mild fatigue after exertion or stress
2. Do you find that you get tired and exhausted easily?
3. Craving for salty foods
4. Sensitive to minor changes in weather and surroundings
5. Dizzy when rising or standing up from a kneeling position
6. Dark bluish or black circles under your eyes
7. Have bouts of nausea with or without vomiting
8. Your body or parts of your body feel tender, sore, sensitive to the touch, hot, and/or painful
9. Feel puffy and swollen all over your body

Rows	0 (No)	8 (Yes)
10. Catch colds or infections easily
11. Wounds heal slowly
12. Skin is gradually tanning without exposure to the sun or the ingestion of high levels of carotene-rich foods (e.g., daily carrot juice intake)

PART IV

SECTION A

When you miss meals or go without food for extended periods of time, do you experience any of the following symptoms?

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. A sense of weakness
2. A sudden sense of anxiety when you get hungry
3. Tingling sensation in your hands
4. A sensation of your heart beating too quickly or forcefully
5. Shaky, jittery, hands trembling
6. Sudden profuse sweating and/or your skin feels clammy
7. Nightmares possibly associated with going to bed on an empty stomach
8. Wake up at night feeling restless
9. Agitation, easily upset, nervous
10. Poor memory, forgetful
11. Confused or disoriented
12. Dizzy, faint
13. Cold or numb
14. Mild headaches or head pounding
15. Blurred vision or double vision
16. Feel clumsy and uncoordinated

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Frequent urination during the day and night
2. Unusual thirst-feeling like you can't drink enough water
3. Unusual hunger-eating all the time
4. Vision blurs
5. Feel itchy all over
6. Tingling or numbness in your feet
7. Sense of drowsiness, lethargy during the day not associated with missing meals or not sleeping

Rows	(0)No	(8)Yes
8. Eating starchy foods, even if they are healthy and unprocessed (like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight
9. Sores heal slowly
10. Loss of hair on your legs

PART V

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Feel jittery
2. First effort of the day causes pain, pressure tightness or heaviness around the chest
3. Exhaustion with minor exertion
4. Heavy sweating (no exertion, no hot flashes
5. Difficulty catching breath, especially during exercise
6. Heart pounding sensation of heart beating too quickly, too slowly or irregularly
7. Swelling in feet, ankles and/or legs comes and goes for no apparent reason

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Muscle pain at rest
2. Cramp-like pains in your ankles, calves or legs
3. Numbness, tingling and prickling sensation in hands and feet
4. Cold feet and/or toes appear blue
5. Brief moments of hearing loss
6. Nausea comes and goes quickly (unrelated to eating)
7. Feel worse standing: legs get heavy and fatigued
8. Leg discomfort or fatigue relieved by elevating legs
9. Fingers and toes get numb in cold weather even when protected

Rows	0 (No)	8 (Yes)
10. Notice changes in your ability to feel pain or differentiate between sensations of hot or cold
11. Body hair (on arm, hands, fingers, legs and toes) is thinning or has disappeared
12. Do you notice a decline in your ability to make decisions, concentrate, focus attention or follow directions?

PART VI

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Family, friends, work, hobbies or activities you hold dear are no longer of interest
2. Do you cry?
3. Does life look entirely hopeless?
4. Would you describe yourself as feeling miserable and sad, unhappy or blue?
5. Do you find it hard to make the best of difficult situations?
6. Sleep problems-too much or too little sleep

Rows	0 (No)	8 (Yes)
7. Changes in your appetite and weight
8. Lately you've noticed an inability to think clearly or concentrate
9. Difficulty making decisions and/or clarifying and achieving your goals

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Does worrying get you down?
2. Does every little thing get on your nerves and wear you out?
3. Would you consider yourself a nervous person?
4. Do you feel easily agitated?
5. Do you shake and tremble?
6. Are you keyed up and jittery?
7. Do you tremble or feel weak when someone shouts at you?
8. Do you become scared at sudden movements or noises at night?
9. Do you find yourself sighing a lot?
10. Are you awakened out of your sleep by frightening dreams?
11. Do frightening thoughts keep coming back in your mind?
12. Do you become suddenly scared for no reason?
13. Do you break out in a cold sweat?
14. "Butterflies in your stomach," nausea and/or diarrhea

SECTION C

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Do you feel pent up and ready to explode?
2. Are you prone to noisy and emotional outbursts?
3. Do you do things on impulse?
4. Are you easily upset or irritated?
5. Do you go to pieces if you don't control yourself?
6. Do little annoyances get on your nerves and make you angry?
7. Does it make you angry to have anyone tell you what to do?
8. Do you flare up in anger if you can't have what you want right away?

PART VII

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Eyes water or tea
2. Mucus discharge from the eyes
3. Ears ache, itch, feel congested or sore
4. Discharge from ears
5. Is your nose continually congested?

Rows	0 (No)	8 (Yes)
6. Are you prone to loud snoring?

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
7. Does your nose run?

Rows 0 (No) 8 (Yes)

8. Nosebleeds

Rows	0 (No)	8 (Yes)
8. Nosebleeds

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
9. Hoarse voice
10. Do you have to clear your throat?
11. Do you feel a choking lump in your throat?

Rows	0 (No)	8 (Yes)
12. Do you suffer from severe colds?
13. Do frequent colds keep you miserable all winter?
14. Flu symptoms last longer than 5 days
15. Do infections settle in your lungs?

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
16. Chest discomfort or pain
17. Do you experience sudden breathing difficulties?
18. Do you struggle with shortness of breath?
19. Difficulty exhaling (breathing out)
20. Breathlessness followed by coughing during exertion, no matter how slight
21. Inability to breathe comfortably while lying down
22. Do you cough up lots of phlegm?
23. Can you hear noisy rattling sounds when breathing in and out?
24. Are you troubled by coughing?
25. Do you wheeze?
26. Do you have severe soaking sweats at night?
27. Do your lips and/or nails have a bluish hue?
28. Are you sleepy during the day?
29. Do you have difficulty concentrating?

Rows	0 (No)	8 (Yes)
30. Eyes, ears, nose, throat and lung symptoms seem associated with specific foods like dairy or wheat products
31. Eyes, ears, nose, throat and lung symptoms are associated with seasonal changes

PART VIII

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Involuntary loss of urine when you cough, lift something or strain during an activity
2. Mild lower back ache or pain
3. Abdominal achiness or pain
4. Pain or burning when urinating
5. Rarely feel the urge to urinate
6. Feel the need to urinate less than every two hours during the day or night
7. Strong smelling urine
8. Back or leg pains are associated with dripping after urination
9. Sore or painful genitals
10. Urine is a rose color
11. Sudden urge to void causes involuntary loss of urine
12. Generalized sense of water retention throughout your body

PART IX

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Bones throughout your entire body ache, feel tender
2. Localized bone pain
3. Hands, feet or throat get tight, spasm or feel numb
4. Difficulty sitting straight
5. Upper back pain
6. Lower back pain
7. Pain when sitting down or walking
8. Find yourself limping or favoring one leg
9. Shins hurt during or after exercise

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Are you stiff in the morning when you wake up?
2. Difficulty bending down and picking up clothing or anything from the floor
3. Joint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)
4. Joints hurt when moving or when carrying weight
5. A routine exercise program, like daily walking, causes your knees to swell or hurt
6. Difficulty opening jars that were previously easy to open
7. Discomfort, numbness, prickling or tingling sensation or pain in neck, shoulder or arm
8. Intermittent pain or ache on one side of the head spreading to the cheek, temple, lower jaw, ear, neck, and shoulder
9. Difficulty chewing food or opening mouth
10. Difficulty standing up from a sitting position
11. Shooting, aching, tingling pain down the back of the leg

Rows	0 (No)	8 (Yes)
12. Is it difficult to reach up and get a 5-pound object like a bag of flour from just above your head?
13. Injure, strain or sprain easily

SECTION C

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Muscles stiff, sore, tense and/or achy
2. Burning, throbbing, shooting or stabbing muscle pain
3. Muscle cramps or spasms (involuntary or after exertion/exercise)
4. Is muscle pain or stiffness greater in the morning than at other times of the day?
5. Specific points on the body feel sore when pressed
6. Feel unrefreshed upon awakening
7. Headaches
8. Pain at the sides of your head or in your face especially when awakening
9. Your jaw clicks or pops
10. Muscle twitch or tremor-eyelids, thumb, calf muscle
11. Irresistible urge to move legs
12. Legs move during sleep
13. Unpleasant crawling sensation inside calves when lying down
14. Hand and wrist numbness or pain (e.g., interferes with writing or with buttoning or unbuttoning your clothes)
15. Feeling of "pin sand needles" in your thumb and first three fingers
16. Pain in the forearm and sometimes in the shoulder

PART X

SECTION A

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Head feels heavy
2. Dizziness
3. Difficulty bending over, standing up from sitting, rolling over in bed and/or turning your head from side to side
4. Your hands tremble, ever so slightly, for no apparent reason
5. You feel like you're wearing heavy weights on your feet when walking
6. Bump into things, trip, stumble and feel clumsy
7. Difficulty breathing
8. Difficulty swallowing
9. People tell you to speak up because they have trouble hearing you
10. Speaking and forming words does not feel automatic
11. Need 10-12 hours of sleep to feel rested
12. Lack of strength (your grip is weak, holding your head or picking your arms up takes effort)

Rows	0 (No)	8 (Yes)
13. Hands get tired when you write and your handwriting is less legible and smaller than it used to be
14. Muscles in arms and legs seem softer and smaller
15. Is your eyesight, sense of smell and taste or ability to hear not as sharp as it used to be
16. Do you find yourself moving slower than you used to?

SECTION B

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Difficulty absorbing new information
2. Tend to forget things
3. Trouble thinking or concentrating
4. Easily distracted
5. Do you have a tendency to become frustrated quickly?
6. Inability to sit still for any length of time, even at mealtime
7. Finishing tasks is easier said than done
8. Do you have more trouble solving problems or managing your time than usual?
9. Low tolerance for stress and otherwise ordinary problems

PART XI

Men only

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Sensation of not emptying your Bladder completely
2. Need to urinate less than 2 hours after you have finished urinating
3. Find yourself needing to stop and start again several times while urinating
4. Find it difficult to postpone urination
5. Have a weak urinary stream
6. Need to push or strain to begin urinating
7. Dripping after urination
8. Urge to urinate several times a night

PART XII

Women Only

(Menopausal women should skip to Sections E and F)

SECTION A

Do you persistently experience any of these symptoms within three days to two weeks prior to menstruation? [A]

Rows	(0)No	(8)Yes
[A]1. Anxious, irritable or restless
2. Numbness, and tingling in hands and feet
3. Easy to anger, resentful
4. Aggressive or hostile toward family/friends
[B]5. Abdominal Moating, feeling swollen (e.g., feet)
6 . Temporary weight gain
7. Breast tenderness, swelling
8. Appearance of breast lumps
9. Discharge from nipples
10. Nausea and/or vomiting
11. Diarrhea or constipation
12. Aches and pains (back, joints, etc.)
[C]13. Craving for sweets
14. Increased appetite or binge eating
15. Headaches
16. Being easily overwhelmed, shaky or clumsy
17. Heart pounding
18. Dizziness or fainting
[D]19. Confused and forgetful to the point that work suffers
20. Overwhelmed with feelings of sadness and worthlessness
21. Difficulty sleeping or falling asleep
22. Engaging in self-destructive behavior

SECTION B (Do you experience any of these symptoms during your period?)

Rows	(0)No	(8)Yes
1. Cramping in the lower abdomen or pelvic area
2. Lower abdominal pain is sharp and/or dull or intermittent
3. Bloating and sense of abdominal fullness
4. Diarrhea or constipation
5. Nausea and/or vomiting
6. Low back and/or legs ache
7. Headaches
8. Unusual fatigue (take naps) resulting in missed work
9. Painful and/or swollen breasts
10. Scanty Mood flow

SECTION C

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Painful or difficult sexual intercourse
2. Low abdominal, back, and vaginal pain throughout the month
3. Pelvic pressure or pain while sitting down or standing up, relieved by lying down
4. Vaginal bleeding other than during your period
5. Painful bowel movements
6. Difficult (straining) urination
7. Abnormal vaginal discharge
8. Offensive vaginal discharge
9. Vaginal itching or burning with or without intercourse

Rows	0 (No)	8 (Yes)
10. Pain during periods is getting progressively worse
11. Profuse or prolonged menstrual bleeding
12. Unable to get pregnant

SECTION D

Rows	0 (No)	8 (Yes)
1. Absence of periods for six months or longer
2. Periods occur irregularly (e.g., 3 to 6 times a year)

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
3. Profuse heavy bleeding during period
4. Menstrual blood contains clots and tissue
5. Bleeding between periods can occur anytime

Rows	0 (No)	8 (Yes)
6. Periods occur greater than every 35 days

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
7. Intense upper stomach pain, lasting several hours at the time you ovulate (approximately day 14 of your cycle)
8. Bleeding occurs at ovulation (approximately day 14 of your cycle)
9. Monthly abdominal pain without bleeding
10. Abundant cervical mucus
11. Acne and/or oily skin
12. Overwhelming urges for sexual intercourse
13. Aggressive feelings

Rows	0 (No)	8 (Yes)
14. Increased growth of dark facial and/or body hair
15. Poor sense of smell
16. Voice is becoming deeper
17. Breasts seem to be getting smaller
18. Receding hairline

SECTION E

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Vaginal discharge
2. Vaginal secretions are watery and thin
3. Vaginal dryness
4. Sexual intercourse is uncomfortable
5. Interest in having sex is low
6. Engorged breasts
7. Breast tenderness, soreness
8. Difficulty with orgasm
9. Vaginal bleeding after sexual intercourse

Rows	0 (No)	8 (Yes)
10. Do you skip periods?
11. The length (number of days) of your period varies month to month, with the number of days of bleeding getting fewer

Consent/Disclaimer Form/HIPPA

I,
hereby attest to the following
- I understand that Dr. Melissa Nelson is a licensed primary care physician in the state of Wisconsin. She is a Doctor of Chiropractic (D.C.) and a federally licensed Certified Nutritionist (C.N.). She is not a Medical Doctor (M.D.) and not performing Medical Diagnostic and treatment procedures.
- The services performed by Dr. Melissa Nelson are at all times restricted to consultation and evaluation on the subject of lifestyle and clinical nutritional matters. These services are intended for the maintenance and optimization of general health and do not involve diagnosing, prognosticating, or treatment of disease.
- That I am consenting to treatment, on this day and any subsequent visit, on my own behalf.
- That my personal health information will not be disclosed without my approval. That I may obtain a copy of privacy practices and policies in writing upon request.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name (Please print)

First NameLast Name
Signature
Mailing Address with Zip code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Format: (000) 000-0000.
Email
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Should be Empty:

Rows	No/Rarely 0	Occasionally 1	Often 4	Frequently 8
1. Sense of well-being fluctuates throughout the day for no apparent reason
2. Sudden hot flashes
3. Spontaneous sweating
4. Chills
5. Cold hands and feet
6. Heart beats rapidly or feels like it is fluttering
7. Numbness, tingling or prickling sensations
8. Dizziness
9. Mental fogginess, forgetful or distracted
10. Inability to concentrate
11. Depression, anxiety, nervousness and/or irritability
12. Difficulty sleeping
13. Conscious of new feelings of anger and frustration
14. Skin, hair, vagina and/or eyes feel dry

HEALTH APPRAISAL QUESTIONNAIRE