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DONNA F. SMITH, C.C.N., C.N.
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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

Women Sports Nutrition Logo
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