healthcheck

Hey there! Use this questionnaire to get an idea of which body systems could be causing symptoms you are experiencing. This questionnaire is not designed to be a source of medical advice, rather a tool to help you tune in to your body and identify symptoms of concern. To act on your results, see a qualified naturopath or medical doctor for advice.
NAME: DATE: 2017-27-06
Section 1 - DIGESTION
 
1.1 - STOMACH
Never Occasionally Moderately / Often Frequently / Daily
1) Indigestion
     
2) Excessive belching, burping
     
3) Bloating or fullness commencing during or shortly after a meal
     
4) Sensation of food sitting in stomach for a prolonged period after a meal
     
5) Bad breath
     
6) Loss of appetite, or nausea
     
7) History of anaemia
 Yes    No  
1.2 - SMALL INTESTINE AND ENZYME FUNCTION
Never Occasionally Moderately / Often Frequently / Daily
1) Indigestion, bloating and fullness for several hours after eating
     
2) Abdominal cramps or aches
     
3) Nausea and/or vomiting
     
4) Excessive passage of gas
     
5) Diarrhoea (loose, watery or frequent bowel movements)
     
6) Constipation (requiring straining, or a hard, dry or small stool)
     
7) Alternating constipation and diarrhoea
     
8) Undigested food in stools
     
9) Stools greasy, smelly or stick to toilet bowl
     
10) Black tarry stools
     
11) Certain foods worsen abdominal symptoms
 Yes    No  
12) Dry flaky skin and dry brittle hair
 Yes    No  
13) Difficulty gaining weight
 Yes    No  
1.4 - COLON
Never Occasionally Moderately / Often Frequently / Daily
1) Lower abdominal pain, cramping and/or spasms
     
2) Lower abdominal pain relieved by passing gas or stool
     
3) Excessive gas and bloating
     
4) Certain foods or stress aggravate lower abdominal pain
     
5) Diarrhoea (loose, watery or frequent bowel movements)
     
6) Constipation (requiring straining, or a hard, dry or small stool)
     
7) Alternating diarrhoea and constipation
     
8) Sensation of incomplete emptying of bowel
     
9) Extremely narrow stools
     
10) Mucus or pus in stool
     
11) Red blood with bowel movement
     
12) Rectal pain or cramps
     
13) Anal itching
     
1.5 - LIVER AND GALL BLADDER
Never Occasionally Moderately / Often Frequently / Daily
1) Upper abdominal pain, or pain under ribs
     
2) Bloating or feeling of fullness after eating
     
3) Excessive belching or gas
     
4) Fatty foods cause indigestion or nausea
     
5) Loss of appetite
     
6) Nausea and/or vomiting
     
7) Unexplained itchy skin
     
8) Yellowish discolouration of skin or eyes, or dark coloured urine
 Yes    No  
9) Pale clay-coloured stools
     
10) Fatigue, malaise or weakness
     
11) Fluid retention, oedema
     
12) Easy bruising, or bleeding (e.g. of gums)
     
13) Loss or thinning of body hair
 Yes    No  
14) Red skin, particularly on palms
 Yes    No  
15) Dry, flaky skin, or dry hair
 Yes    No  
Section 6 – URINARY
 
YOU ARE
 Male    Female