Personal Health Assessment [PHA]

Start of GutStrong

Personal Health Assessment [PHA]
Instructions...
1. At the end of the first page (section) click the SAVE button. This will prompt you to create an account (with JotForm) which then emails you a link email link to your saved form. Check junk/spam folder if the link is not in your inbox. Email comes from noreply@jotform.com
2. At the end of every page (section) ENSURE you click the SAVE button, then click NEXT if you are still continuing. This way you will never lose any inputted information. Your JotForm email link will take you to the place on the form where you left off.
Today's Date

DayMonthYear
Date
Full Name*

First NameLast Name
Email Address*
example@example.com

HEALTH, MEDICATIONS AND SUPPLEMENTS
Using ONE line per issue... List ALL your health issues, conditions, disorders etc. (even little niggles) you are CURRENTLY experiencing*
Using ONE line per each medication... List all prescribed medications (including contraceptives) AND any over-the-counter drugs (e.g. Nurofen, Panadol etc.) you are currently taking (not supplements) If NONE, please type in NONE*
Using ONE line per each Supplement... List all supplements that you take (even if sporadic) If NONE, please type in NONE*

SLEEP
How many hours of sleep do you get (on average)*
Your average 'hours' of sleep
Ease of Falling Asleep... rating*
Refers to the time it takes to fall asleep once you put your head on the pillow
Awakenings... *
Refers to the number of times you WAKE UP during 'sleep hours'
Ease of Falling back to sleep after waking... rating.*
Refers to how easily you fall back to sleep after waking

DIGESTION…
Heartburn... rating*
Signs are… Burning sensation in the chest or throat, often felt after eating or lying down. Regurgitation: A sour or bitter-tasting acid that backs up into your throat or mouth, especially when bending over or lying down. Difficulty swallowing (dysphagia): A feeling of food being stuck in your chest or throat.
Reflux... rating*
Signs are… Regurgitation: Feeling of food and acid coming up into the throat. Chest pain: Such as sharp or dull chest discomfort, especially after eating. Bloating: A feeling of fullness or pressure in the abdomen. Nausea or upset stomach: Especially after eating. Worsening symptoms when lying down or after eating: Tends to worsen when lying flat or after a large or spicy meal.
Belching or Burping... rating*
Signs are… Release of air from the mouth, either loud or soft can be accompanied by a feeling of fullness or pressure in the upper abdomen.
Bloating... rating*
Signs are… When your abdomen feels swollen or distended, or a feeling of tightness. Your stomach may appear larger than usual, and your clothes may feel tighter around your waist.
Flatulence (gas)... rating*
Signs are… a release of gas from the digestive system through the rectum.
Abdominal pain, cramps or spasms... rating*
Signs are… A dull or sharp ache, cramping, or tenderness in the stomach area. You may feel a build-up of pressure in the abdomen, leading to increased gas expulsion.
Cravings... rating*
Signs are… An intense desire or urge to eat specific types of food, often outside of regular hunger cues. It is a strong desire for a particular food or taste i.e. sweet or salty snacks.
Bowel movements... frequency*
How many bowel movements a day
Bowel movements... Describe timing, speed, colour, odour*
Please refer to the time(s) of day you pass a bowel movement. Speed… How long does it take to pass? Colour… Black, Brown, Red, Greenish, Orange'ish, Yellow’ish, Pale grey? Consistency… Separate hard lumps like nuts? Sausage shaped but lumpy? Sausage like cracked surface? Smooth Sausage like? Soft blobs with clear cut edges? Fluffy with ragged edges/mushy? Watery, no solid pieces? Sticky/Greasy? Odour… None? Bad odour? Or smells like?
One line per food... List the foods you are sensitive/Intolerant to *

ENERGY…
Energy on waking... rating*
Energy - throughout the day... rating*
Energy - from evening to bedtime... rating*

RESPIRATORY AND CIRCULATION...
Asthma and/or Wheezing.. rating*
Hay fever .. rating*
Dark circles under eyes .. rating*
Bags or puffiness under eyes .. rating*
Phlegm in throat and/or postnasal drip .. rating*
Refers to sensation of mucus dripping down the back of the throat from the nasal passages. Constant throat clearing, coughing (esp. at night), sore or scratchy throat, discomfort when swallowing, excessive swallowing to clear your throat. If NEVER, please write "never
Swollen legs, ankles and/or feet .. rating*
Swollen arms, wrists and/or hands... rating*

ACHES AND PAINS...
Headaches and/or Migraines.. rating*
A headache is a pain or discomfort in the head, scalp, or neck. Where as a migraine typically cause moderate to severe throbbing pain, often on one side of the head. Can last from hours to days. May be accompanied by nausea, vomiting, and sensitivity to light or sound.
Body aches, pains or spasms... rating*
Refers to any type of ache, pain or spasm anywhere in the body
Briefly state where the aches, pains and spasms are...
Restless leg syndrome [RLS]... rating*
Refers to an irresistible urge to move the legs, often accompanied by uncomfortable sensations, particularly in the evening or at night, making it difficult to fall or stay asleep. The condition can be mild or severe and sensations experienced can be a feeling of crawling, tingling, throbbing, pulling sensation, pins or needles or itching feeling in the legs. The urge to move the legs usually occurs during periods of rest or inactivity, particularly when sitting or lying down.

Measurements
⚠️ IMPORTANT: Complete these measurements at the start of your program, then do not weigh or measure yourself again until the end. We mean it.

Why? Because true, lasting health is not built by focusing on the number on the scale. That keeps you stuck in short-term thinking. When you focus on your daily behaviours and health, you create sustainable, long-term change.
Height (in centimetres)… Please have someone measure for you, do NOT estimate*
Just enter the number NOT the word "cm"
Weight (in kilograms)… Take a note at what time of day, with or without clothes, that you weighed yourself. Do NOT weigh yourself during the program!!*
Just enter the number NOT the word "kg"
Chest (in centimetres)… Measure around the largest part of your chest (breasts) with the tape across nipples. *
Just enter the number NOT the word "cm"
Waist (in centimetres)… Measure at the narrowest part of your waist. *
Just enter the number NOT the word "cm"
Please calculate your Waist-to-height ratio [WHtR] by dividing your waist circumference by your height e.g. 80(cm) Waist ➗161(cm) height = 0.49 (enter this number)*
From the WHtR above, select category*
Waist to Height Ratio [WHtR] is a tool for predicting cardiovascular, diabetes and stroke risk, hypertension, and dyslipidemia because it accounts for the distribution of abdominal fat, which is known to increase the aforementioned risks. The WHtR is a measure of fat distribution. A superior tool to detect cardiometabolic risk factors.
Hips (in centimetres)… Measure around the largest part of your buttocks with your heels together.*
Just enter the number NOT the word "cm"
Right thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest*
Just enter the number NOT the word "cm"
Left thigh (in centimetres) … Stand with your legs slightly apart, measure where the circumference is largest*
Just enter the number NOT the word "cm"
Right bicep (in centimetres) … Measure midway between the top of your shoulder and elbow *
Just enter the number NOT the word "cm". Note: you're not measuring your left bicep.
Calculate your Body mass index [BMI] by entering your weight in kilograms and height in centimetres below
From the BMI rating above select category*
Body Mass Index [BMI] is just one of the many tools used to measure ‘size’, relating to body fat, not dependent on your frame. Correlated with total body fat, it does not distinguish fat from muscle or different body fat distributions.

Visual Health Record

Photos are one of the most powerful tools you can use to track your progress. While numbers on a scale or measurements can tell part of the story, photos often reveal changes you might not notice day to day. They capture posture, shape, skin health, and overall vitality in ways that written notes cannot. These images will remain private and secure. This is OPTIONAL
Full standing photos (side on view) — fully clothed or in bra/underwear, whichever you’re most comfortable with.

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Full standing photos (front on view) — fully clothed or in bra/underwear, whichever you’re most comfortable with.

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Now take a MOMENT now to SAVE this document (again). If you think of something you'd like to add, click the BACK button and amend or add. Finally (optional) tell yourself how you feel about having done this PHA. You'll get to look at it again in the future when you compare it to the END, so think about it as talking to your future self about how you feel right NOW.
Please verify that you are human*
Should be Empty:

Start of GutStrong

HEALTH, MEDICATIONS AND SUPPLEMENTS

SLEEP

MOOD, STRESS & CONCENTRATION…

DIGESTION…

ENERGY…

SKIN, HAIR, NAILS, MOUTH…

RESPIRATORY AND CIRCULATION...

ACHES AND PAINS...

HORMONES, URINARY...

Measurements

Visual Health Record