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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
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ROBERT J. WOLFF, D.C.
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T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Health Appraisal Comprehensive
Part 1-4

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.

Date:
Name:
E-Mail:
WSN Acct. No.:

Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Carefully and completely select the number that best describes the frequency of your symptoms. If a symptom applies to you and is asked more than once, answer it each time the symptom appears on the form. Females: Answer all questions in each section for "Females Only." If you are menopausal (naturally or by hysterectomy), answer all questions in each female section, except those related to menstruation.

Answer:	0 = None or Rarely
	1 = Twice a week or less
	2 = 3-6 times a week
	3 = Daily

PART 1 - Section A

1. Indigestion, "sour stomach"	0	1	2	3
2. Excessive belching, burping and/or bloating	0	1	2	3
3. Gas immediately following a meal	0	1	2	3
4. Sense of fullness during and after meals	0	1	2	3
5. Poor appetite, disinterest in food	0	1	2	3
6. Offensive breath	0	1	2	3
7. Bad taste in mouth	0	1	2	3
8. Partial loss of taste or smell	0	1	2	3
9. Difficult bowel movements	0	1	2	3
10. Difficulty swallowing	0	1	2	3
11. Unintentional weight loss			Yes 5	No
12. History of anemia, unresponsive to iron			Yes 5	No
13. Vegetarian (no eggs, dairy)			Yes 3	No
14. Picky eater			Yes 3	No
15. Spoon-shaped nails			Yes 3	No
16. Sores in corner of mouth			Yes 3	No
17. Smooth tongue			Yes 3	No

Total Part 1 - Section A

Part 1 - Section B

1. Indigestion and fullness lasts 2-4 hours after eating	0	1	2	3
2. Pain, tenderness, soreness on the left side under rib cage	0	1	2	3
3. Bloated	0	1	2	3
4. Excessive passage of gas	0	1	2	3
5. Abdominal cramps, aches	0	1	2	3
6. Nausea and/or "vomiting"	0	1	2	3
7. Dry flaky skin, dry brittle hair	0	1	2	3
8. Difficulty gaining weight	0	1	2	3
9. Weakness and fatigue	0	1	2	3
10. Specific foods/beverages aggravate indigestion	0	1	2	3
11. Roughage and fiber cause constipation	0	1	2	3
12. Three or more large bowel movements daily	0	1	2	3
13. Alternating constipation and diarrhea	0	1	2	3
14. Stool poorly formed	0	1	2	3
15. Stool - undigested food	0	1	2	3
16. Stool - greasy, shiny	0	1	2	3
17. Stool yellowish, foul smelling	0	1	2	3
18. Mucus in stool	0	1	2	3
19. Black stool	0	1	2	3
20. Rectal spasms	0	1	2	3
21. Dark urine	0	1	2	3
22. Bone and back pain	0	1	2	3
23. Pounding heart	0	1	2	3
24. Iron deficiency anemia			Yes 3	No

Total Part 1 - Section B

PART 1 - Section C

1. Stomach pain, burning, aching 1-4 hours after eating	0	1	2	3
2. Feeling hungry an hour or two after eating	0	1	2	3
3. Strong emotions, thought, smell of food aggravates stomach	0	1	2	3
4. Heartburn, especially when lying down or bending forward	0	1	2	3
5. Heartburn due to spicy and fatty foods, chocolate, peppers, citrus, alcohol, caffeine	0	1	2	3
6. Difficulty or pain when swallowing	0	1	2	3
7. Chest pain, difficulty breathing, lung infections	0	1	2	3
8. Constipation, difficult bowel movements	0	1	2	3
9. Black, tarry stool	0	1	2	3
10. Unexplained weight gain			Yes 3	No
11. Temporary relief using antacids, carbonated beverages, cream, milk, or food			Yes 5	No
12. Digestive problems subside with rest and relaxation			Yes 5	No

Total Part 1 - Section C

PART 1 - Section D

1. Lower abdominal pain, cramping and/or spasms	0	1	2	3
2. Lower abdominal pain relief by passing stool or gas	0	1	2	3
3. Raw fruits, vegetables and stress aggravate bowel pain	0	1	2	3
4. Diarrhea (loose watery stool)	0	1	2	3
5. More than three bowel movements daily	0	1	2	3
6. Excessive gas and bloating	0	1	2	3
7. Painful, difficult, straining during bowel movements	0	1	2	3
8. Hard, dry or small stool	0	1	2	3
9. Extremely narrow stools, thin stool	0	1	2	3
10. Alternating diarrhea/constipation	0	1	2	3
11. Mucus and pus in stool	0	1	2	3
12. Feeling that bowels do not empty completely	0	1	2	3
13. Rectal pain or cramps	0	1	2	3
14. Bright red blood following bowel movement	0	1	2	3
15. Anal itching	0	1	2	3
16. Irritable, moody	0	1	2	3
17. Rash under breast, armpit, around naval or groin area			Yes 5	No
18. Feeling ill in damp, moldy setting or rainy weather			Yes 3	No

Total Part 1 - Section D

PART 2 - Section A

1. Moderate to severe pain under right side of rib cage	0	1	2	3
2. Abdominal pain worse with deep breathing	0	1	2	3
3. Bitter fluid repeats after eating	0	1	2	3
4. Bloated, full feeling	0	1	2	3
5. Belching, heartburn, gas	0	1	2	3
6. Fatty foods cause indigestion	0	1	2	3
7. Nausea and/or vomiting	0	1	2	3
8. Chronic fatigue	0	1	2	3
9. Unexplained itchy skin worse at night	0	1	2	3
10. Yellowing cast to skin, eyes	0	1	2	3
11. Stool color alternates from clay colored to normal brown	0	1	2	3
12. General feeling of poor health	0	1	2	3
13. Fatigue, weakness, exhaustion	0	1	2	3
14. Unable to concentrate, irritable, confused	0	1	2	3
15. Aching muscles	0	1	2	3
16. Trembling hands	0	1	2	3
17. Weight gain due to water retention	0	1	2	3
18. Swollen feet and/or legs	0	1	2	3
19. Bleeding tendencies in gums, nose	0	1	2	3
20. Loss of chest and armpit hair	0	1	2	3
21. Reddened skin, especially palms	0	1	2	3
22. Dark urine, diminished flow	0	1	2	3
23. Dry, flaky skin and/or hair			Yes 3	No
24. Loss of appetite and weight			Yes 3	No
25. Easy bruising			Yes 3	No
26. Thinning of pubic hair			Yes 3	No
27. Feeling of extreme dryness			Yes 3	No
28. Loss of skin elasticity			Yes 3	No

Total Part 2 - Section A

PART 2 - Section B

1. Tired, sluggish	0	1	2	3
2. Feel cold - hands, feet, all over	0	1	2	3
3. Tight sensation in neck	0	1	2	3
4. Difficult, infrequent bowel movements	0	1	2	3
5. Dryness, discoloration skin, hair	0	1	2	3
6. Thick, brittle nails	0	1	2	3
7. Puffy face, hands and feet	0	1	2	3
8. Swollen upper eyelids	0	1	2	3
9. Eyeballs move involuntarily	0	1	2	3
10. Muscles weak, cramp and/or tremble	0	1	2	3
11. Slow mental processes, forgetfulness	0	1	2	3
12. Slow heart beats	0	1	2	3
13. Abdominal swelling	0	1	2	3
14. Unsteady gait, movements	0	1	2	3
15. Lack of interest in sex	0	1	2	3
16. Gain weight easily			Yes 5	No
17. Swelling of the neck			Yes 5	No
18. Outer third of eyebrow thins			Yes 3	No
19. Thinning hair on scalp, face and genitals			Yes 3	No
20. Loss of appetite			Yes 3	No
21. Premenstrual tension			Yes 3	No
22. Inferti1ity			Yes 3	No
23. Excessive menstrual bleeding			Yes 3	No
24. Absence of periods			Yes 3	No

Total Part 2 - Section B

PART 3 - Section A

1. Progressive, mild fatigue after exertion or stress	0	1	2	3
2. General weakness	0	1	2	3
3. Blurred vision, dizzy when rising	0	1	2	3
4. Depression	0	1	2	3
5. Rapid mood swings	0	1	2	3
6. Irritable	0	1	2	3
7. Dark circles under the eyes	0	1	2	3
8. Abdominal pain, indigestion	0	1	2	3
9. Bouts of nausea, vomiting	0	1	2	3
10. Diarrhea or constipation	0	1	2	3
11. Blotchy skin (white patches)	0	1	2	3
12. Cravings for salty foods	0	1	2	3
13. Decreased appetite			Yes 3	No
14. Gradual weight loss			Yes 3	No
15. Tan skin, no sun			Yes 3	No
16. Gradual loss of body hair			Yes 3	No
17. Black freckles on upper forehead, face, neck			Yes 3	No
18. Sensitive to minor changes in weather and surroundings			Yes 5	No

Total Part 3 - Section A

PART 3 - Section B

1. Catch colds easily	0	1	2	3
2. Infections - eyes, ears, nose, throat, lungs, skin	0	1	2	3
3. Diarrhea	0	1	2	3
4. Puffy face	0	1	2	3
5. Dark areas on cheeks, under eyes	0	1	2	3
6. Difficulty seeing at night	0	1	2	3
7. Eyes tear, burn, discharge	0	1	2	3
8. Ears, continuously drain	0	1	2	3
9. Nasal congestion or discharge - thick, yellow, green	0	1	2	3
10. Sore throat or post-nasal drip	0	1	2	3
11. Cough with mucus	0	1	2	3
12. Inflamed or bleeding gums	0	1	2	3
13. Cold sores, fever blisters	0	1	2	3
14. Gums swelling, bleeding	0	1	2	3
15. Unexplained weight loss of 10 pounds in last three months			Yes 3	No
16. Lack of appetite			Yes 3	No
17. Nail discolorations			Yes 3	No
18. Bumpy skin on back of arms			Yes 3	No
19. Wounds heal slowly			Yes 3	No
20. Hair is easily plucked out or falls out, grows slow			Yes 3	No
21. Lips are red and swollen			Yes 3	No
22. Tongue is red, swollen, raw looking			Yes 3	No
23. Impaired taste and smell			Yes 3	No
24. Neck, armpit, groin swelling			Yes 5	No

Total Part 3 - Section B

PART 3 - Section C

1. Muscles fatigue quickly	0	1	2	3
2. Moody, irritable, tired	0	1	2	3
3. Severe fatigue	0	1	2	3
4. Severe joint pain, redness swelling	0	1	2	3
5. Chronic pain, stiffness throughout body	0	1	2	3
6. Migraine headaches	0	1	2	3
7. Specific food(s) worsen pain, inflammation, stiffness	0	1	2	3
8. Sensitive to light (skin or eyes)	0	1	2	3
9. Dark circles under eyes	0	1	2	3
10. Swollen-looking face or body	0	1	2	3
11. Localized or general itching - eyes, ears, throat, nose, skin	0	1	2	3
12. Clear, watery discharge from nose, eyes	0	1	2	3
13. Extreme dryness of eyes, nasal passages, mouth	0	1	2	3
14. Sneezing	0	1	2	3
15. Cough or wheezing	0	1	2	3
16. Moldy, damp environments trigger sickness	0	1	2	3
17. Post nasal drip with certain foods	0	1	2	3
18. Heart palpitations after eating certain foods	0	1	2	3
19. Weight loss, muscle weakness			Yes 3	No
20. Scalp hair falls out easily, in clumps			Yes 3	No
21. Hair loss, entire body			Yes 5	No
22. Easy bruising			Yes 3	No
23. Nails - loosened, pitted, discolored			Yes 5	No

Total Part 3 - Section C

PART 4 - Section A

1. Sense of being overly tired	0	1	2	3
2. Prolonged recovery after exercise	0	1	2	3
3. Coldness, especially in hands and feet	0	1	2	3
4. Difficulty breathing on exertion, palpitations	0	1	2	3
5. Headache, dizziness, spots before eyes	0	1	2	3
6. Irritable	0	1	2	3
7. Forgetful, poor concentration	0	1	2	3
8. Mild yellowing of eyes or skin	0	1	2	3
9. Ringing in ears	0	1	2	3
10. Susceptible to infections	0	1	2	3
11. Jaundice and dark urine	0	1	2	3
12. Black stool (no iron supplements)	0	1	2	3
13. Unusual cravings for clay, dirt, ice	0	1	2	3
14. Fingernails are flattened, spoon-shaped brittle, thin			Yes 5	No
15. White patches on skin			Yes 3	No
16. Pale lips, gums, eyelids nail beds			Yes 3	No
17. Red, sore tongue			Yes 3	No
18. Mouth, throat, rectum ulcers			Yes 3	No
19. Unusual bruising			Yes 3	No
20. Spontaneous bleeding - nose, mouth, gums, rectum or vagina			Yes 3	No
21. Small red cots under the skin			Yes 3	No
22. Sores in the corner of mouth			Yes 3	No
23. Smooth tongue			Yes 3	No

Total Part 4- Section A

PART 4 - Section B

1. Nosebleeds	1	2	3
2. Headache, typically in morning	1	2	3
3. Weakness, fatigue, nervous	1	2	3
4. Ringing in ears	1	2	3
5. Dizziness, drowsiness	1	2	3
6. Blushing - no apparent cause	1	2	3
7. Numbness, tingling in hand and feet	1	2	3
8. Blurred vision	1	2	3

Total Part 4- Section B

PART 4 - Section C

1. Feel jittery	1	2	3
2. Heartburn that moves to neck, jaws, left shoulder and arm	1	2	3
3. First effort of the day causes pain around chest	1	2	3
4. Dizziness	1	2	3
5. Choking, smothering sensation	1	2	3
6. Exhausted with minor exertion	1	2	3
7. Heart pounds easily	1	2	3
8. Heavy sweating (no exertion)	1	2	3
9. Mild or severe chest pain	1	2	3
10. Difficulty catching breath especially during exercise	1	2	3
11.Wheezing or dry cough	1	2	3
12. Heart palpitations - slow, rapid or irregular	1	2	3
13. Swelling in feet, ankle, legs - comes and goes	1	2	3
14. Veins on neck are prominent	1	2	3

Total Part 4- Section C

PART 4 - SECTION D

1. Fluid retention	0	1	2	3
2. Numbness, tingling, pricking sensation in hands, feet	0	1	2	3
3. Muscle pain in the calves or thighs when walking	0	1	2	3
4. Muscle pain at rest	0	1	2	3
5. Cold feet	0	1	2	3
6. Headaches	0	1	2	3
7. Dizziness, everything spins	0	1	2	3
8. Poor concentration	0	1	2	3
9. Slurred speech	0	1	2	3
10. Ringing in ears	0	1	2	3
11. Brief moments of hearing loss	0	1	2	3
12. Nausea comes and goes quickly	0	1	2	3
13. Falling without known cause	0	1	2	3
14. Brief difficulty swallowing	0	1	2	3
15. Brief difficulty speaking	0	1	2	3
16. Stammering or twitching of tongue	0	1	2	3
17. Double vision	0	1	2	3
18. Difficulty understanding spoken or written word	0	1	2	3
19. Brief loss of muscular coordination in legs, arms	0	1	2	3
20. Inability to recognize persons or things that pass very quickly	0	1	2	3
21. Inability to feel pain or temperature, usually on one side, that disappears quickly	0	1	2	3
22. One leg or arm - shiny, hairless skin			Yes 5	No
23. Discolored or blue toes			Yes 5	No
24. Open sores on feel and legs			Yes 5	No
25. Fingers and toes numb in response to cold weather even when protected			Yes 5	No

Total Part 4- Section D