HEALTH QUESTIONNAIRE

Forename
Surname
Email

Rate each of the following symptoms based upon your typical health profile for the past 6 months:

Point Scale
0 – Never or almost never have the symptom 3 – Frequently have it, effect is not severe
1 – Occasionally have it, effect is not severe 4 – Frequently have it, effect is severe
2 – Occasionally have it, effect is severe

head

0 1 2 3 4
Headaches
Faintness
Dizziness
Insomnia
Total 0

eyes

0 1 2 3 4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Total 0

ears

0 1 2 3 4
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total 0

nose

0 1 2 3 4
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total 0

mouth/throat

0 1 2 3 4
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total 0

skin

0 1 2 3 4
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Total 0

heart

0 1 2 3 4
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total 0

lungs

0 1 2 3 4
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total 0

digestive tract

0 1 2 3 4
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total 0

joints/muscle

0 1 2 3 4
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total 0

weight

0 1 2 3 4
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Total 0

energy/activity

0 1 2 3 4
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total 0

mind

0 1 2 3 4
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total 0

emotions

0 1 2 3 4
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total 0

other

0 1 2 3 4
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total 0
 
Grand Total 0

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