Better Health Documents - Madasafish
HEALTH APPRAISAL QUESTIONNAIRE 3
NAME:
Date:
| |Dry skin | |Biliousness | |Laxative often used |
| |Skin rashes frequently | |Greasy foods upset | |History of gall stones |
| |Bitter, metallic taste in mouth in | |Stools light coloured | |Sneezing attacks |
| |morning | | | | |
| |Bowel movements painful or | |Pain between shoulder blades | | |
| |difficult | | | | |
| |Lower bowel gas several hours after| |Coated tongue | |Gas shortly after eating |
| |eating | | | | |
| |Burning stomach sensation relieved | |Indigestion ½ - 1 hour after | |Stomach bloating after eating |
| |by eating | |eating, or up to 3 – 4 hours | | |
| |Pulse fast at rest | |Low blood pressure | |Hot flushes |
| |Nervousness | |Failing memory | |Headaches |
| |Can’t gain weight | |Increased sex drive | |Dizziness |
| |Intolerance to heat | |Splitting headaches | |Increase in blood pressure |
| |Highly emotional | |Decrease sugar tolerance | |Sugar in urine |
| |Flush easily | | | |Masculine tendencies (women) |
| |Night sweats | | | |Low blood pressure |
| |Inward trembling | |Intestinal bloating | |Chronic fatigue |
| |Heart palpitates | |Abnormal thirst | |Weakness dizziness |
| |Insomnia | |Weight gain (hips or waist) | |Tendency to hives |
| |Impaired hearing | |Sex desire reduced | |Arthritic tendencies |
| |Decrease appetite | |Tendency to ulcers, colitis | |Perspiration increase |
| |Ringing in ears | |Increased sugar tolerance | |Crave salt |
| |Constipation | |Women: menstrual disorder | |Brown spots / brown skin |
| |Mental sluggishness | |Young girls: lack of menstruation | |Allergies, asthma |
| |Headaches on waking | | | |Exhaustion – muscular, nervous |
| |Slow pulse | | | |Respiratory disorders |
| |Weight gain | | | | |
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