Health Assessment Step 1 of 36 2% Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleEmail* Section 1: Gastrointestinal1.1: HypoacidityIndigestion:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive belching, burping:*NeverOccasionallyModerately/OftenFrequently/DailyBloating or fullness commencing during or shortly after a meal:*NeverOccasionallyModerately/OftenFrequently/DailySensation of food sitting in stomach for a prolonged period after a meal:*NeverOccasionallyModerately/OftenFrequently/DailyBad breath:*NeverOccasionallyModerately/OftenFrequently/DailyLoss of appetite, or nausea:*NeverOccasionallyModerately/OftenFrequently/DailyHistory of Anaemia:*YesNo Section 1: Gastrointestinal1.2: HyperacidityStomach pain, burning or aching, 1-4 hours after eating:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling hungry just an hour or two after eating:*NeverOccasionallyModerately/OftenFrequently/DailyIndigestion or heartburn from spicy or fatty food, citrus, alcohol, or caffine:*NeverOccasionallyModerately/OftenFrequently/DailyStomach discomfort or pain in response to strong emotions, thoughts, or smell of food:*NeverOccasionallyModerately/OftenFrequently/DailyHeartburn aggravated by lying down or bending forward:*NeverOccasionallyModerately/OftenFrequently/DailyAntacids, carbonated beverages, milk, cream or food relieve the above symptoms:*NeverOccasionallyModerately/OftenFrequently/DailyConstipation:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty or pain when swallowing:*NeverOccasionallyModerately/OftenFrequently/DailyBlack tarry stools:*NeverOccasionallyModerately/OftenFrequently/DailyVomiting blood or vomitus has appearance of coffee-grounds:*NeverOccasionallyModerately/OftenFrequently/Daily Section 1: Gastrointestinal1.3: Small Intestine/PancreasIndigestion, bloating and fullness for several hours after eating:*NeverOccasionallyModerately/OftenFrequently/DailyAbdominal cramps or aches:*NeverOccasionallyModerately/OftenFrequently/DailyNausea and/or vomiting:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive passage of gas:*NeverOccasionallyModerately/OftenFrequently/DailyDiarrhoea (loose, watery or frequent bowel movements):*NeverOccasionallyModerately/OftenFrequently/DailyConstipation (requiring straining, or a hard, dry or small stool):*NeverOccasionallyModerately/OftenFrequently/DailyAlternating constipation and Diarrhoea:*NeverOccasionallyModerately/OftenFrequently/DailyUndigested food in stools:*NeverOccasionallyModerately/OftenFrequently/DailyStools greasy, smelly or stick to toilet bowel:*NeverOccasionallyModerately/OftenFrequently/DailyBlack tarry stools:*NeverOccasionallyModerately/OftenFrequently/DailyCertain foods worsen abdominal symptoms:*YesNoDry flaky skin and dry brittle hair:*YesNoDifficulty gaining weight:*YesNo Section 1: Gastrointestinal1.4: ColonLower abdominal pain, cramping and/or spasms:*NeverOccasionallyModerately/OftenFrequently/DailyLower abdominal pain relieved by passing gas or stool:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive gas and bloating:*NeverOccasionallyModerately/OftenFrequently/DailyCertain foods or stress aggravate lower abdominal pain:*NeverOccasionallyModerately/OftenFrequently/DailyDiarrhoea (loose, watery or frequent bowel movements):*NeverOccasionallyModerately/OftenFrequently/DailyConstipation (requiring straining, or a hard, dry or small stool):*NeverOccasionallyModerately/OftenFrequently/DailyAlternating constipation and Diarrhoea:*NeverOccasionallyModerately/OftenFrequently/DailySensation of incomplete emptying of bowel:*NeverOccasionallyModerately/OftenFrequently/DailyExtremely narrow stools:*NeverOccasionallyModerately/OftenFrequently/DailyMucus or pus in stool:*NeverOccasionallyModerately/OftenFrequently/DailyRed blood with bowel movement:*NeverOccasionallyModerately/OftenFrequently/DailyRectal pain or cramps:*NeverOccasionallyModerately/OftenFrequently/DailyAnal itching:*NeverOccasionallyModerately/OftenFrequently/Daily Section 1: Gastrointestinal1.5: Liver/Gall Bladder/PancreasUpper Abdominal pain, or pain under ribs:*NeverOccasionallyModerately/OftenFrequently/DailyBloating or feeling of fullness after eating:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive belching or gas:*NeverOccasionallyModerately/OftenFrequently/DailyFatty foods cause indigestion or nausea:*NeverOccasionallyModerately/OftenFrequently/DailyLoss of appetite:*NeverOccasionallyModerately/OftenFrequently/DailyNausea and/or vomiting:*NeverOccasionallyModerately/OftenFrequently/DailyUnexplained itchy skin:*NeverOccasionallyModerately/OftenFrequently/DailyYellowish discolouration of skin or eyes, or dark coloured urine:*YesNoPale clay-coloured stools:*NeverOccasionallyModerately/OftenFrequently/DailyFatigue, malaise or weakness:*NeverOccasionallyModerately/OftenFrequently/DailyFluid retention, Oedema:*NeverOccasionallyModerately/OftenFrequently/DailyEasy bruising, or bleeding (e.g. of gums):*NeverOccasionallyModerately/OftenFrequently/DailyLoss or thinning of body hair:*YesNoRed skin, particularly on palms:*YesNoDry, flaky skin, or dry hair:*YesNo Section 2: Endocrine2.1: Symptoms of underactive thyroidFatigue, sluggishness:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling cold, or intolerance to cold:*NeverOccasionallyModerately/OftenFrequently/DailySwelling or tightness in front of neck:*YesNoConstipation (requiring straining, or a hard, dry or small stool):*NeverOccasionallyModerately/OftenFrequently/DailyDry skin and hair:*YesNoPuffy face, hands or feet:*NeverOccasionallyModerately/OftenFrequently/DailyGaining of weight, or decreased appetite:*YesNoLow mood:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, poor memory:*NeverOccasionallyModerately/OftenFrequently/DailyLow libido:*NeverOccasionallyModerately/OftenFrequently/DailyInfertility:*YesNoHeavier or more frequent menstrual periods:*YesNo Section 2: Endocrine2.2: Symptoms of overactive thyroidFatigue, notable weakness in limbs:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling hot, or intolerance to heat, sweaty:*NeverOccasionallyModerately/OftenFrequently/DailySwelling or tightness in front of neck:*YesNoDiarrhoea (loose, watery or frequent bowel movements):*NeverOccasionallyModerately/OftenFrequently/DailyWeight loss, possibly with increased appetite:*YesNoPalpitations:*NeverOccasionallyModerately/OftenFrequently/DailyNervousness, irritability, restlessness:*NeverOccasionallyModerately/OftenFrequently/DailyTremor:*NeverOccasionallyModerately/OftenFrequently/DailyInsomnia:*NeverOccasionallyModerately/OftenFrequently/DailyVisual disturbance, problems with eyes, or development of staring gaze:*NeverOccasionallyModerately/OftenFrequently/DailyPoor libido:*NeverOccasionallyModerately/OftenFrequently/DailyLight, infrequent or absent menstrual periods:*YesNo Section 2: Endocrine2.3: Stress, fatigue and adrenalsFeeling stressed, nervous, or tense, or unable to relax:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling irritable or oversensitive:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling overwhelmed, unable to cope:*NeverOccasionallyModerately/OftenFrequently/DailyLow mood, mood swings:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating or thinking clearly, memory problems:*NeverOccasionallyModerately/OftenFrequently/DailyNeed coffee, tea, tobacco, sugar or chocolate as pick me ups:*NeverOccasionallyModerately/OftenFrequently/DailyFatigued, tire easily:*NeverOccasionallyModerately/OftenFrequently/DailyFind it hard to get up and going in the morning:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty staying awake during day:*NeverOccasionallyModerately/OftenFrequently/DailyInsomnia:*NeverOccasionallyModerately/OftenFrequently/DailyPalpitations or chest pain:*NeverOccasionallyModerately/OftenFrequently/DailyNausea, dizziness:*NeverOccasionallyModerately/OftenFrequently/DailyChange in appetite:*NeverOccasionallyModerately/OftenFrequently/Daily Section 3: Immune3.1: Low ImmunityFrequent colds or flu:*YesNoFrequent infections in other locations (e.g. bladder, skin):*YesNoDiarrhoea:*NeverOccasionallyModerately/OftenFrequently/DailyEars continuously drain:*NeverOccasionallyModerately/OftenFrequently/DailyNasal congestion or discharge:*NeverOccasionallyModerately/OftenFrequently/DailySore throat:*NeverOccasionallyModerately/OftenFrequently/DailyCough with mucus:*NeverOccasionallyModerately/OftenFrequently/DailyCold sores:*NeverOccasionallyModerately/OftenFrequently/DailyInflamed or bleeding gums, or swollen, red lips or tongue:*NeverOccasionallyModerately/OftenFrequently/DailyWounds heal slowly:*YesNoExcessive loss of hair:*YesNoNeck, armpit or groin swelling:*NeverOccasionallyModerately/OftenFrequently/Daily Section 3: Immune3.2: AllergyMigraine or non-migraine headache:*NeverOccasionallyModerately/OftenFrequently/DailySensitivity to light (skin or eyes):*NeverOccasionallyModerately/OftenFrequently/DailyDark circles under eyes:*NeverOccasionallyModerately/OftenFrequently/DailySwollen eyes, lips, face, or other body parts:*NeverOccasionallyModerately/OftenFrequently/DailyLocalised or general itching - eyes, ears, throat, nose, skin:*NeverOccasionallyModerately/OftenFrequently/DailyRashes or eczema:*NeverOccasionallyModerately/OftenFrequently/DailyClear watery discharge from nose or eyes:*NeverOccasionallyModerately/OftenFrequently/DailySneezing, coughing or wheezing:*NeverOccasionallyModerately/OftenFrequently/DailyIrritability, fatigue:*NeverOccasionallyModerately/OftenFrequently/DailyCertain foods worsen symptoms, or cause palpitations:*YesNo Section 4: Cardiovascular4.1: Healthy red blood cell maintenanceExcessive fatigue:*NeverOccasionallyModerately/OftenFrequently/DailyProlonged recovery after exercise:*NeverOccasionallyModerately/OftenFrequently/DailyProlonged recovery after exercise:*NeverOccasionallyModerately/OftenFrequently/DailyDizziness, spots before eyes, or ringing in ears:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, poor memory:*NeverOccasionallyModerately/OftenFrequently/DailyYellowing of eyes or skin:*YesNoPale eyelids, lips, gums, nails:*NeverOccasionallyModerately/OftenFrequently/DailyRed sore tongue:*NeverOccasionallyModerately/OftenFrequently/DailySores in corner of mouth:*NeverOccasionallyModerately/OftenFrequently/DailyEasy bruising or bleeding:*NeverOccasionallyModerately/OftenFrequently/Daily Section 4: Cardiovascular4.2: Healthy blood pressure maintenanceHeadaches:*NeverOccasionallyModerately/OftenFrequently/DailyNosebleeds:*NeverOccasionallyModerately/OftenFrequently/DailyRedness in face:*NeverOccasionallyModerately/OftenFrequently/DailyRinging in ears or blurred vision:*NeverOccasionallyModerately/OftenFrequently/DailyHistory of high blood pressure:*YesNo Section 4: Cardiovascular4.3: HeartPalpitations:*NeverOccasionallyModerately/OftenFrequently/DailyDizziness:*NeverOccasionallyModerately/OftenFrequently/DailyPain or heaviness in central chest:*NeverOccasionallyModerately/OftenFrequently/DailyHeartburn, pain or heavy crushing sensation that moves to neck, jaw, left shoulder or arm:*NeverOccasionallyModerately/OftenFrequently/DailyPallor or sweating with chest discomfort or with unusual indigestion:*NeverOccasionallyModerately/OftenFrequently/DailyFatigue easily, poor exercise tolerance:*NeverOccasionallyModerately/OftenFrequently/DailyShortness of breath with exertion:*NeverOccasionallyModerately/OftenFrequently/DailyShortness of breath lying flat in bed, or sudden shortness of breath in the middle of the night:*NeverOccasionallyModerately/OftenFrequently/DailyWheezing or dry cough:*NeverOccasionallyModerately/OftenFrequently/DailyVeins on neck are prominent:*NeverOccasionallyModerately/OftenFrequently/DailySwelling in feet, ankles or legs:*NeverOccasionallyModerately/OftenFrequently/DailyHistory of high blood cholesterol:*YesNo Section 4: Cardiovascular4.4: Circulatory SystemPoor circulation in extremities: coldness, or numbness, tingling or pricking sensations in hands or feet, discolouration in fingures or toes:*NeverOccasionallyModerately/OftenFrequently/DailyUlcers on feet or legs:*YesNoMuscle pain in calves or thighs with walking:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, poor memory:*NeverOccasionallyModerately/OftenFrequently/DailyFaints, or falls with unknown cause:*NeverOccasionallyModerately/OftenFrequently/DailyBrief periods of difficulty speaking, swallowing, or understanding speech or written word:*NeverOccasionallyModerately/OftenFrequently/DailyBrief periods of loss of whole or part of vision, double vision, impaired coordination, or areas of numbness:*NeverOccasionallyModerately/OftenFrequently/Daily Section 5: Glucose Tolerance5.1: Symptoms of hypoglycaemia - When you miss a meal, do you feel...Fatigue and weakness, or feeling shaky:*NeverOccasionallyModerately/OftenFrequently/DailyMild headache:*NeverOccasionallyModerately/OftenFrequently/DailySweating or palpitations:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling light-headed or faint:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, poor memory, confusion:*NeverOccasionallyModerately/OftenFrequently/DailyAgitation, irritability:*NeverOccasionallyModerately/OftenFrequently/Daily Section 5: Glucose Tolerance5.2: Symptoms of hyperglycaemiaExcessive, frequent urination:*NeverOccasionallyModerately/OftenFrequently/DailyIncreased thirst and appetite:*NeverOccasionallyModerately/OftenFrequently/DailyBlurred vision, failing eyesight:*NeverOccasionallyModerately/OftenFrequently/DailyFatigue, drowsiness:*NeverOccasionallyModerately/OftenFrequently/DailyProfuse sweating:*NeverOccasionallyModerately/OftenFrequently/DailyDizziness when standing from sitting position:*NeverOccasionallyModerately/OftenFrequently/DailyUnintentional weight loss, or excesive weight gain:*NeverOccasionallyModerately/OftenFrequently/DailyRecurrent or persistent infections (e.g. bladder, skin):*NeverOccasionallyModerately/OftenFrequently/DailyUlcers on feet or legs:*YesNoSlow wound healing:*YesNoDiagnosis of diabetes:*YesNo Section 6: Genitourinary System and Reproductive Hormones6.1: Kidney/BladderFluid retention throughout body:*NeverOccasionallyModerately/OftenFrequently/DailyLower back pain:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive urination:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive urination during night:*NeverOccasionallyModerately/OftenFrequently/DailyBurning with urination:*NeverOccasionallyModerately/OftenFrequently/DailyFrequent urination:*NeverOccasionallyModerately/OftenFrequently/DailyUrgency of urination:*NeverOccasionallyModerately/OftenFrequently/DailyBloody, cloudy or darkened urine, or strong-smelling urine:*NeverOccasionallyModerately/OftenFrequently/DailyIncontinence:*NeverOccasionallyModerately/OftenFrequently/DailyIncontinence:*NeverOccasionallyModerately/OftenFrequently/DailyInfrequent urination:*NeverOccasionallyModerately/OftenFrequently/DailyGrey cast to skin:*NeverOccasionallyModerately/OftenFrequently/DailySevere one-sided lower back or groin pain associated with restlessness:*NeverOccasionallyModerately/OftenFrequently/DailyHistory of kidney stones:*YesNo Section 6: Genitourinary System and Reproductive Hormones6.3: Symptoms of PMS - Symptoms experienced in the 3 to 14 days prior to menstruation, in the last 3 monthsInsomnia:*NeverOccasionallyModerately/OftenFrequently/DailyAbdominal bloating:*NeverOccasionallyModerately/OftenFrequently/DailyBreast tenderness, swelling or lumps:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling depressed, teary, or sensitive:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling anxious, irritable, or easily angered:*NeverOccasionallyModerately/OftenFrequently/DailyDiarrhoea or constipation:*NeverOccasionallyModerately/OftenFrequently/DailyHeadaches or migraines:*NeverOccasionallyModerately/OftenFrequently/DailyFood cravings or binge eating:*NeverOccasionallyModerately/OftenFrequently/DailyBack pain:*NeverOccasionallyModerately/OftenFrequently/DailyFluid retention or weight gain:*NeverOccasionallyModerately/OftenFrequently/DailyClumsiness:*NeverOccasionallyModerately/OftenFrequently/DailyFeeling aggressive, or feeling suicidal:*NeverOccasionallyModerately/OftenFrequently/Daily Section 6: Genitourinary System and Reproductive Hormones6.4: Menstrual irregularities - Symptoms experienced in the past 3 months Irregular intervals between periods:*YesNoLong period cycles, greater than 32 days:*YesNoShort period cycles, less than 24 days:*YesNoVaginal bleeding between periods:*YesNoPainful periods - lower abdomen or back:*NeverOccasionallyModerately/OftenFrequently/DailyPain with periods is worsening:*YesNoPainful intercourse during menstruation:*NeverOccasionallyModerately/OftenFrequently/DailyPelvic and/or rectal pressure around menstruation:*NeverOccasionallyModerately/OftenFrequently/DailyConstipation or diarrhoea with menstruation:*NeverOccasionallyModerately/OftenFrequently/DailyNausea and/or vomiting with mentruation:*NeverOccasionallyModerately/OftenFrequently/DailyLight blood flow:*YesNoHeavy blood flow, or flooding:*YesNoPassage of large or profuse blood clots:*YesNoProlonged duration of bleeding:*YesNoProlonged duration of bleeding: Number of Days:*Absense of menstrual flow for more than 5 months:*YesNo Section 6: Genitourinary System and Reproductive Hormones6.5: Symptoms of menopause Irregular menstrual cycle and/or changes in menstrual flow (heavier or lighter):*YesNoDry skin, hair or vagina:*NeverOccasionallyModerately/OftenFrequently/DailyLow libido:*NeverOccasionallyModerately/OftenFrequently/DailyMood swings, irritability, depression, nervousness, anxiety:*NeverOccasionallyModerately/OftenFrequently/DailyHot flushes:*NeverOccasionallyModerately/OftenFrequently/DailyNight sweats:*NeverOccasionallyModerately/OftenFrequently/DailyHeadaches or dizziness:*NeverOccasionallyModerately/OftenFrequently/DailyPainful intercourse:*NeverOccasionallyModerately/OftenFrequently/DailyInsomnia:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, poor memory, or confusion:*NeverOccasionallyModerately/OftenFrequently/DailyThinning of armpit and pubic hair, or increased hair growth on upper lip:*YesNoBreasts reducing in size and starting to sag:*YesNo Section Section 6: Genitourinary System and Reproductive Hormones6.6: Healthy female hormone balance Vaginal dryness or pain:*NeverOccasionallyModerately/OftenFrequently/DailyPainful intercourse:*NeverOccasionallyModerately/OftenFrequently/DailyMilk production (not nursing), or engorged breasts:*NeverOccasionallyModerately/OftenFrequently/DailyLow libido:*NeverOccasionallyModerately/OftenFrequently/DailyExcessive libido:*NeverOccasionallyModerately/OftenFrequently/DailyAcne and/or oily skin:*NeverOccasionallyModerately/OftenFrequently/DailyExcess facial hair:*YesNoBreasts shrinking:*YesNoThinning body hair:*YesNoInfertility:*YesNoMiscarriage:*YesNoVaginal discharge: excesive, smelly, or coloured:*NeverOccasionallyModerately/OftenFrequently/DailyBurning or itching of external genitalia:*NeverOccasionallyModerately/OftenFrequently/DailyVaginal bleeding after intercourse, or between periods:*NeverOccasionallyModerately/OftenFrequently/DailyLower abdominal or back pain:*NeverOccasionallyModerately/OftenFrequently/DailyBreast lumps, or a change in breast size or shape:*YesNoNipple discharge, or change in appearance of nipple:*NeverOccasionallyModerately/OftenFrequently/DailySwelling under armpit:*YesNo Section 7: Musculoskeletal7.1: Bone Generalised bone tenderness or achiness:*NeverOccasionallyModerately/OftenFrequently/DailyLocalised bone pain:*NeverOccasionallyModerately/OftenFrequently/DailyBone deformity or swelling:*YesNoShins hurt during or after exercise:*NeverOccasionallyModerately/OftenFrequently/DailyLow back or hip pain:*NeverOccasionallyModerately/OftenFrequently/DailyWalking difficulties, or a limp:*NeverOccasionallyModerately/OftenFrequently/DailyHearing loss, headaches, ringing in ears:*YesNoDiagnosis of osteoporosis:*YesNoAbnormal spinal curvature:*YesNoRecent loss of height:*YesNoBowed legs:*YesNoStooped posture or hump at base of neck:*YesNoUnexplained bone fracture:*YesNo Section 7: Musculoskeletal 7.2: Musculoskeletal Muscle aches and pains:*NeverOccasionallyModerately/OftenFrequently/DailyMuscle stiffness, tension:*NeverOccasionallyModerately/OftenFrequently/DailySpecific body points are tender to touch:*NeverOccasionallyModerately/OftenFrequently/DailyHeadaches:*NeverOccasionallyModerately/OftenFrequently/DailyFatigue:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty sleeping:*NeverOccasionallyModerately/OftenFrequently/DailyMuscle cramps or spasms:*NeverOccasionallyModerately/OftenFrequently/DailyMuscles twitch or tremble:*NeverOccasionallyModerately/OftenFrequently/DailyRestless legs:*NeverOccasionallyModerately/OftenFrequently/DailyUpper or lower back pain:*NeverOccasionallyModerately/OftenFrequently/DailyMuscle weakness:*NeverOccasionallyModerately/OftenFrequently/DailyMuscle loss and wasting:*YesNo Section 7: Musculoskeletal7.3: Connective tissue Tender, red, swollen, and stiff joints:*NeverOccasionallyModerately/OftenFrequently/DailyDry mouth, dry, painful eyes:*NeverOccasionallyModerately/OftenFrequently/DailyCreaking (noisy) joints:*NeverOccasionallyModerately/OftenFrequently/DailyLimp:*NeverOccasionallyModerately/OftenFrequently/DailyShooting, aching, tingling pain down back of leg:*NeverOccasionallyModerately/OftenFrequently/DailyJoint pain involves more than one joint:*NeverOccasionallyModerately/OftenFrequently/DailyLimited range of motion:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty standing up from seated position:*NeverOccasionallyModerately/OftenFrequently/DailyImpaired mobility or function:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty chewing or opening mouth:*NeverOccasionallyModerately/OftenFrequently/DailyNumbness, prickling, tingling sensation in neck, shoulders or arms:*NeverOccasionallyModerately/OftenFrequently/DailyInjure, strain, sprain easily:*YesNoRed, painless skin lumps on elbows, knees, toes:*YesNoKnobbly joints:*YesNoMuscle wasting:*YesNo Section 8: Brain and Nervous System8.1: Neurological Headache:*NeverOccasionallyModerately/OftenFrequently/DailyLight-headedness, fainting:*NeverOccasionallyModerately/OftenFrequently/DailyRinging or buzzing in ears:*NeverOccasionallyModerately/OftenFrequently/DailyTrembling hands:*NeverOccasionallyModerately/OftenFrequently/DailyWeakness:*NeverOccasionallyModerately/OftenFrequently/DailyNumbness, pins and needles, or tingling in limbs:*NeverOccasionallyModerately/OftenFrequently/DailyUnsteady on feet:*NeverOccasionallyModerately/OftenFrequently/DailyPoor hand coordination:*NeverOccasionallyModerately/OftenFrequently/DailyConvulsions, seizures or funny turns:*NeverOccasionallyModerately/OftenFrequently/DailyDifficulty concentrating, confused, poor memory:*NeverOccasionallyModerately/OftenFrequently/DailyClumsy:*NeverOccasionallyModerately/OftenFrequently/DailyDrooping eyelid(s):*NeverOccasionallyModerately/OftenFrequently/DailyImpaired hearing, eyesight, sense of touch, smell or taste:*NeverOccasionallyModerately/OftenFrequently/DailySlow or slurred speech:*NeverOccasionallyModerately/OftenFrequently/DailyIncontinence:*NeverOccasionallyModerately/OftenFrequently/Daily Section 8: Brain and Nervous System8.2: Stress history - In past 2 years have you experienced... Divorce:*YesNoSeparation from partner:*YesNoMarriage:*YesNoDeath of close family member or friend:*YesNoLoss of work, retirement or starting a new job:*YesNoBankruptcy, or a major change in finances:*YesNoMoving house:*YesNoMajor personal injury or illness:*YesNoViolations of the law:*YesNo Section 8: Brain and Nervous System8.3: Symptoms of insomnia - Do you... Have an overactive mind, or worry excessively:*NeverOccasionallyModerately/OftenFrequently/DailyLive or work in a stressful environment:*NeverOccasionallyModerately/OftenFrequently/DailySuffer from constant pain or discomfort:*NeverOccasionallyModerately/OftenFrequently/DailyEat chocolate or drink caffeine in the evenings:*NeverOccasionallyModerately/OftenFrequently/DailyHave difficulty falling asleep or staying asleep:*NeverOccasionallyModerately/OftenFrequently/DailyEat after 8pm:*NeverOccasionallyModerately/OftenFrequently/Daily Section 8: Brain and Nervous System8.4: Normal, healthy learning and concentration - Do you... Find it difficult to keep still or are fidgety:*NeverOccasionallyModerately/OftenFrequently/DailyHave a short attention span:*NeverOccasionallyModerately/OftenFrequently/DailyFind it difficult to relax:*NeverOccasionallyModerately/OftenFrequently/DailyExperience mental confusion or sluggishness:*NeverOccasionallyModerately/OftenFrequently/DailyHave or had learning difficulties:*YesNoHave food allergies:*YesNo Section 9: Respiratory9.1: Respiratory Shortness of breath, increased effort to breathe:*NeverOccasionallyModerately/OftenFrequently/DailyWheezing:*NeverOccasionallyModerately/OftenFrequently/DailyShallow breathing:*NeverOccasionallyModerately/OftenFrequently/DailyCough, dry or moist:*NeverOccasionallyModerately/OftenFrequently/DailyThick yellow, greenish or brown sputum:*NeverOccasionallyModerately/OftenFrequently/DailyBlood in sputum:*NeverOccasionallyModerately/OftenFrequently/DailyFrothy sputum:*NeverOccasionallyModerately/OftenFrequently/DailyNoisy rattling sounds when breathing:*NeverOccasionallyModerately/OftenFrequently/DailyPain in chest:*NeverOccasionallyModerately/OftenFrequently/DailyBad breath or sputum smells offensive:*NeverOccasionallyModerately/OftenFrequently/DailyLoud snoring:*NeverOccasionallyModerately/OftenFrequently/DailyColds always go to the chest:*YesNoBluish nails or lips:*NeverOccasionallyModerately/OftenFrequently/Daily Section 10: Hair, Skin and Nails10.1: Hair, Skin and Nails Acne:*NoneMildModerateSeverePsoriasis:*NoneMildModerateSevereEczema/dermatitis:*NoneMildModerateSevereWarts:*NoneMildModerateSevereTinea:*NoneMildModerateSevereDandruff:*NoneMildModerateSevereRashes:*NoneMildModerateSevereAreas of increased pigmentation:*NoneMildModerateSevereAreas of decreased pigmentation:*NoneMildModerateSevereUnusual or changing moles:*YesNoAreas of unexplained redness:*NoneMildModerateSevereUndiagnosed skin lumps/bumps:*YesNoDiscoloured nails:*NoneMildModerateSeverePitted nails:*NoneMildModerateSevereWeak/brittle nails:*NoneMildModerateSevereThickened nails:*NoneMildModerateSevere Section 11: Detoxification (capacity)11.1: Detoxification - As far as you are aware, do you have a sensitivity or allergy to... The preservatives sodium benzoate or potassium benzoate:*NoneMildModerateSevereTyramine (red wine, cheese, bananas, chocolate):*NoneMildModerateSevereCaffeine:*NoneMildModerateSevereChemicals such as fragrances, exhaust fumes, cigarette smoke or other strong odours:*NoneMildModerateSevereEven small amounts of alcohol:*NoneMildModerateSevereDo you have a history of exposure to chemicals such as herbicides, insecticides, pesticides or organic solvents:*YesNoAlcohol (number of drinks per week):*01-78-1415+Coffee or other caffeinated drinks (number per day):*01-23-45+Smoking (number per day):*09-1820+Smoking (type):*If not currently smoking, have you quit smoking in the last year:*YesNoRecreational drugs:*YesNoRecreational Drugs (type):*What is your blood type:* Section 12: General Health History12.1: Patient health history Frequency of exercise (days per week):*6-73-51-20Vegetarian or vegan:*YesNoAge 50 years:*YesNoPlanning to have a baby in the next 3-6 months:*YesNoPregnant or breastfeeding:*YesNo Section 12: General Health History12.2: Weight management Do you diet often:*YesNoAre you unhappy with your weight:*YesNo Section 12: General Health History12.3: High risk symptoms Unexplained weight loss:*YesNoNight sweats:*NeverOccasionallyModerately/OftenFrequently/DailyFevers:*NeverOccasionallyModerately/OftenFrequently/DailyLumps, e.g. breast, armpit, skin:*YesNoReduced appetite:*NeverOccasionallyModerately/OftenFrequently/DailySevere fatigue:*NeverOccasionallyModerately/OftenFrequently/Daily Section 12: General Health History12.4: Which of the following types of medications have you taken in the last 6 months Asthma medications/inhalers:*YesNoAnti-diabetics/insulin:*YesNoSteroids e.g. cortisone:*YesNoAnti-inflammatories/aspirin:*YesNoParacetamol:*YesNoHeart:*YesNoThyroid:*YesNoAntihistamines:*YesNoAntiulcer medications, antacids:*YesNoAntibiotics / antifungals:*YesNoAntipsychotics:*YesNoRelaxants/sleeping tablets:*YesNoHormones/oral contraceptives:*YesNoChemotherapy:*YesNoAny other medications:*List the nutritional or herbal supplements you are currently taking: List any major health problems in past, surgery, etc: List your major health concerns at present: Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness: Select the save button if you wish to save your completed answers before continuing on to the next page or if you would like to save your answers and return to complete the questionnaire at a later date. 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