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:

2017-17-08

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

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

12) Dry flaky skin and dry brittle hair

Yes

13) Difficulty gaining weight

Yes

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

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

14) Red skin, particularly on palms

Yes

15) Dry, flaky skin, or dry hair

Yes

NAME:

DATE:

2017-17-08

Section 2 – ENDOCRINE FUNCTION

2.1 – UNDERACTIVE THYROID

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Fatigue, sluggishness

2) Fatigue, sluggishnessFeeling cold, or intolerance to cold

3) Swelling or tightness in front of neck

Yes

4) Constipation (requiring straining, or a hard, dry or small stool)

5) Dry skin and hair

Yes

6) Puffy face, hands or feet

7) Gaining of weight, or decreased appetite

Yes

8) Low mood

9) Difficulty concentrating, poor memory

10) Low libido

11) Infertility

Yes

12) Heavier or more frequent menstrual periods

Yes

2.2 - OVERACTIVE THYROID

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Fatigue, notable weakness in limbs

2) Feeling hot, or intolerance to heat, sweaty

3) Swelling or tightness in front of neck

Yes

4) Diarrhoea (loose, watery or frequent bowel movements)

5) Weight loss, possibly with increased appetite

Yes

6) Palpitations

7) Nervousness, irritability, restlessness

8) Tremor

9) Insomnia

10) Visual disturbance, problems with eyes, or development of staring gaze

11) Poor libido

12) Light, infrequent or absent menstrual periods

Yes

2.3 - STRESSES AND ADRENAL FUNCITON

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Feeling stressed, nervous, or tense, or unable to relax

2) Feeling irritable or oversensitive

3) Feeling overwhelmed, unable to cope

4) Low mood, mood swings

5) Difficulty concentrating or thinking clearly, memory problems

6) Need coffee, tea, tobacco, sugar or chocolate as pick me ups

7) Fatigued, tire easily

8) Find it hard to get up and going in the morning

9) Difficulty staying awake during day

10) Insomnia

11) Palpitations or chest pain

12) Nausea, dizziness

13) Change in appetite

NAME:

DATE:

2017-17-08

Section 3 – IMMUNE FUNCTION

3.1 - LOWERED IMMUNITY

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Frequent colds or flu

Yes

2) Frequent infections in other locations (e.g. bladder, skin)

Yes

3) Diarrhoea

4) Ears continuously drain

5) Nasal congestion or discharge

6) Sore throat

7) Cough with mucus

8) Cold sores

9) Inflamed or bleeding gums, or swollen, red lips or tongue

10) Wounds heal slowly

Yes

11) Excessive loss of hair

Yes

12) Neck, armpit or groin swelling

3.2 - ALLERGY SIGNS

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Migraine or non-migraine headache

2) Sensitivity to light (skin or eyes)

3) Dark circles under eyes

4) Swollen eyes, lips, face, or other body parts

5) Localised or general itching – eyes, ears, throat, nose, skin

6) Rashes or eczema

7) Clear watery discharge from nose or eyes

8) Sneezing, coughing or wheezing

9) Irritability, fatigue

10) Certain foods worsen symptoms, or cause palpitations

Yes

NAME:

DATE:

2017-17-08

Section 4 – CARDIOVASCULAR

4.1 RED BLOOD CELLS

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Excessive fatigue

2) Prolonged recovery after exercise

3) Low exercise tolerance, shortness of breath with exertion

4) Dizziness, spots before eyes, or ringing in ears

5) Difficulty concentrating, poor memory

6) Yellowing of eyes or skin

Yes

7) Pale eyelids, lips, gums, nails

8) Red sore tongue

9) Sores in corner of mouth

10) Easy bruising or bleeding

4.2 - BLOOD PRESSURE

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Headaches

2) Nosebleeds

3) Redness in face

4) Ringing in ears or blurred vision

5) History of high blood pressure

Yes

4.3 - HEART

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Palpitations

2) Dizziness

3) Pain or heaviness in central chest

4) Heartburn, pain or heavy crushing sensation that moves to neck, jaw, left shoulder or arm

5) Pallor or sweating with chest discomfort or with unusual indigestion

6) Fatigue easily, poor exercise tolerance

7) Shortness of breath with exertion

8) Shortness of breath lying flat in bed, or sudden shortness of breath in the middle of the night

9) Wheezing or dry cough

10) Veins on neck are prominent

11) Swelling in feet, ankles or legs

12) History of high blood cholesterol

Yes

4.4 - CIRCULATION

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Poor circulation in extremities: coldness, or numbness, tingling or pricking sensations in hands or feet, discolouration in fingers or toes

2) Ulcers on feet or legs

Yes

3) Muscle pain in calves or thighs with walking

4) Difficulty concentrating, poor memory

5) Faints, or falls with unknown cause

6) Brief periods of difficulty speaking, swallowing, or understanding speech or written word

7) Brief periods of loss of whole or part of vision, double vision, impaired coordination, or areas of numbness

NAME:

DATE:

2017-17-08

Section 5 – GLUCOSE BALANCE

5.1 - GLUCOSE CONTROL

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Fatigue and weakness, or feeling shaky

2) Mild headache

3) Sweating or palpitations

4) Feeling light-headed or faint

5) Difficulty concentrating, poor memory, confusion

6) Agitation, irritability

5.2 - HIGH BLOOD GLUCOSE

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Excessive, frequent urination

2) Increased thirst and appetite

3) Blurred vision, failing eyesight

4) Fatigue, drowsiness

5) Profuse sweating

6) Dizziness when standing from sitting position

7) Unintentional weight loss, or excessive weight gain

8) Recurrent or persistent infections (e.g. bladder, skin)

9) Ulcers or sores on legs or feet

Yes

10) Slow wound healing

Yes

11) Diagnosis of diabetes

Yes

Section 6 – URINARY

YOU ARE

Male

Female

6.1 - KIDNEY AND BLADDER

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Fluid retention throughout body

2) Lower back pain

3) Excessive urination

4) Excessive urination during night

5) Burning with urination

6) Frequent urination

7) Urgency of urination

8) Bloody, cloudy or darkened urine, or strong-smelling urine

9) Incontinence

10) Infrequent urination

11) Grey cast to skin

12) Severe one-sided lower back or groin pain associated with restlessness

13) History of kidney stones

Yes

6.2 - MALE REPRODUCTIVE

Never

Occasionally

Moderately / Often

Frequently / Daily

14) Difficulty starting urine flow, or poor flow of urine

15) Sense of bladder fullness, incomplete emptying, or needing to strain with small amounts of urine passed

16) Dripping after urination

17) Ejaculation causes pain

18) Blood in semen

19) Low libido

20) Difficulty attaining or maintaining an erection

21) Premature ejaculation

22) Low energy level or stamina

23) Infertility, low sperm count or poor motility

Yes

24) Inflammation of penis, or unusual discharge from penis

Yes

25) Genital or groin rash, irritation, itchiness or infection

26) Painful testicle(s)

27) Testicles uneven in size, texture or hardness

Yes

28) Both testicles appear smaller

Yes

29) Loss or thinning of body or facial hair, or slow hair growth

Yes

30) Development of breasts or nipple tenderness

Yes

6.1 - KIDNEY AND BLADDER

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Fluid retention throughout body

2) Lower back pain

3) Excessive urination

4) Excessive urination during night

5) Burning with urination

6) Frequent urination

7) Urgency of urination

8) Bloody, cloudy or darkened urine, or strong-smelling urine

9) Incontinence

10) Infrequent urination

11) Grey cast to skin

12) Severe one-sided lower back or groin pain associated with restlessness

13) History of kidney stones

Yes

6.3 - PMS SYMPTOMS

Never

Occasionally

Moderately / Often

Frequently / Daily

14) Insomnia

15) Abdominal bloating

16) Breast tenderness, swelling or lumps

17) Feeling depressed, teary, or sensitive

18) Feeling anxious, irritable, or easily angered

19) Diarrhoea or constipation

20) Headaches or migraines

21) Food cravings or binge eating

22) Back pain

23) Fluid retention or weight gain

24) Clumsiness

25) Feeling aggressive, or feeling suicidal

6.4 - MENSTURAL CYCLE

Never

Occasionally

Moderately / Often

Frequently / Daily

26) Irregular intervals between periods

Yes

27) Long period cycles, greater than 32 days

Yes

28) Short period cycles, less than 24 days

Yes

29) Vaginal bleeding between periods

Yes

30) Painful periods – lower abdomen or back

31) Pain with periods is worsening

Yes

32) Painful intercourse during menstruation

33) Pelvic and/or rectal pressure around menstruation

34) Constipation or diarrhoea with menstruation

35) Nausea and/or vomiting with menstruation

36) Light blood flow

Yes

37) Heavy blood flow, or flooding

Yes

38) Passage of large or profuse blood clots

Yes

39) Prolonged duration of bleeding

Yes

40) Number of days

41) Absence of menstrual flow for more than 5 months

Yes

6.5 - SYMPTOMS OF MENOPAUSE

Never

Occasionally

Moderately / Often

Frequently / Daily

42) Irregular menstrual cycle and/or changes in menstrual flow (heavier or lighter)

Yes

43) Dry skin, hair or vagina

44) Low libido

45) Mood swings, irritability, depression, nervousness, anxiety

46) Hot flushes

47) Night sweats

48) Headaches or dizziness

49) Painful intercourse

50) Insomnia

51) Difficulty concentrating, poor memory, or confusion

52) Thinning of armpit and pubic hair, or increased hair growth on upper lip

Yes

53) Breasts reducing in size and starting to sag

Yes

6.6 – FEMALE REPRODUCTIVE ISSUES

Never

Occasionally

Moderately / Often

Frequently / Daily

54) Swelling under armpit

Yes

55) Vaginal dryness or pain

56) Painful intercourse

57) Milk production (not nursing), or engorged breasts

58) Low libido

59) Excessive libido

60) Acne and/or oily skin

61) Excess facial hair

Yes

62) Breasts shrinking

Yes

63) Thinning body hair

Yes

64) Infertility

Yes

65) Miscarriage

Yes

66) Vaginal discharge: excessive, smelly, or coloured

67) Burning or itching of external genitalia

68) Vaginal bleeding after intercourse, or between periods

69) Lower abdominal or back pain

70) Lower abdominal or back painBreast lumps, or a change in breast size or shape

Yes

71) Nipple discharge, or change in appearance of nipple

NAME:

DATE:

2017-17-08

Section 7 – MUSCULOSKELETAL

7.1 – MUSCLES

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Muscle aches and pains

2) Muscle stiffness, tension

3) Specific body points are tender to touch

Yes

4) Headaches

5) Fatigue

6) Difficulty sleeping

7) Muscle cramps or spasms

8) Muscles twitch or tremble

Yes

9) Restless legs

10) Upper or lower back pain

11) Muscle weakness

12) Muscle loss and wasting

Yes

7.2 – CONNECTIVE TISSUE

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Tender, red, swollen, and stiff joints

2) Dry mouth, dry, painful eyes

3) Creaking (noisy) joints

4) Limp

5) Shooting, aching, tingling pain down back of leg

6) Joint pain involves more than one joint

7) Limited range of motion

8) Difficulty standing up from seated position

9) Impaired mobility or function

10) Difficulty chewing or opening mouth

11) Numbness, prickling, tingling sensation in neck, shoulders or arms

12) Injure, strain, sprain easily

Yes

13) Red, painless skin lumps on elbows, knees, toes

Yes

14) Knobbly joints

Yes

15) Muscle wasting

Yes

NAME:

DATE:

2017-17-08

Section 8 – BRAIN AND NERVOUS SYSTEM

8.1 - NEUROLOGICAL

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Headache

2) Light-headedness, fainting

3) Ringing or buzzing in ears

4) Trembling hands

5) Weakness

6) Numbness, pins and needles, or tingling in limbs

7) Unsteady on feet

8) Easily fatigued

9) Poor hand coordination

10) Convulsions, seizures or funny turns

11) Difficulty concentrating, confused, poor memory

12) Clumsy

13) Drooping eyelid(s)

14) Impaired hearing, eyesight, sense of touch, smell or taste

15) Slow or slurred speech

16) Incontinence

8.2 - STRESS HISTORY

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Divorce

Yes

2) Separation from partner

Yes

3) Marriage

Yes

4) Death of close family member or friend

Yes

5) Loss of work, retirement or starting a new job

Yes

6) Bankruptcy, or a major change in finances

Yes

7) Moving house

Yes

8) Major personal injury or illness

Yes

9) Violations of the law

Yes

8.3 - SLEEP

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Have an overactive mind, or worry excessively

2) Live or work in a stressful environment

3) Suffer from constant pain or discomfort

4) Eat chocolate or drink caffeine in the evenings

5) Have difficulty falling asleep or staying asleep

6) Eat after 8pm

8.4 - MEMORY, LEARNING AND CONCENTRATION

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Find if difficult to keep still or are fidgety

2) Have a short attention span

3) Find it difficult to relax

4) Experience mental confusion or sluggishness

5) Have or had learning difficulties

Yes

6) Have food allergies

Yes

NAME:

DATE:

2017-17-08

Section 9 – REPIRATORY SYSTEM

Questions

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Shortness of breath, increased effort to breathe

2) Wheezing

3) Shallow breathing

4) Cough, dry or moist

5) Thick yellow, greenish or brown sputum

6) Blood in sputum

7) Frothy sputum

8) Noisy rattling sounds when breathing

9) Pain in chest

10) Bad breath or sputum smells offensive

11) Loud snoring

12) Colds always “go to the chest”

Yes

13) Bluish nails or lips

NAME:

DATE:

2017-17-08

Section 10 – HAIR SKIN AND NAILS

Questions

Never

Occasionally

Moderately / Often

Frequently / Daily

1) Acne

2) Psoriasis

3) Eczema/dermatitis

4) Warts

5) Tinea

6) Dandruff

7) Rashes

8) Areas of increased pigmentation

9) Areas of decreased pigmentation

10) Unusual or changing moles

Yes

11) Areas of unexplained redness

12) Undiagnosed skin lumps/bumps

Yes

13) Discoloured nails

14) Pitted nails

15) Weak/brittle nails

16) Thickened nails

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