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Office (940) 761-4045
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Copyright 1999
Donna F. Smith

Health Appraisal Comprehensive
Part 5-10

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.:

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 5 - Section A

1. Sudden anxiety associated with hunger	1	2	3
2. Tingling sensation in hands	1	2	3
3. Palpitations	1	2	3
4. Feel shaky, jittery, tremors	1	2	3
5. Weakness	1	2	3
6. Profuse perspiration, clammy	1	2	3
7. Nightmares	1	2	3
8. Awake from sleep restless	1	2	3
9. Agitated, easily upset, nervous	1	2	3
10. Poor memory, forgetful	1	2	3
11. Confusion, disoriented	1	2	3
12. Dizziness, feel faint	1	2	3
13. Feeling cold, numbness	1	2	3
14. Mild headaches	1	2	3
15. Blurred or double vision	1	2	3
16. Lack of coordination	1	2	3

PART 5 - Section A

PART 5 - Section B

1. Excessive, frequent urination	0	1	2	3
2. Increased thirst and appetite	0	1	2	3
3. Blurred vision, failing eyesight	0	1	2	3
4. Fatigue, drowsiness	0	1	2	3
5. Crave sweets, but eating sweets does not relieve craving	0	1	2	3
6. Feel hungry for air (can't get enough)	0	1	2	3
7. Breath smells sweet	0	1	2	3
8. Depressed	0	1	2	3
9. Tingling, numbness, prickling sensation in extremities	0	1	2	3
10. Profuse sweating	0	1	2	3
11. Dribble after voiding	0	1	2	3
12. Impotency	0	1	2	3
13. Dizziness when standing from sitting position	0	1	2	3
14. Slurred speech	0	1	2	3
15. Unintentional weight loss			Yes 3	No
16. Reoccurring persistent infection bladder, skin or gums			Yes 3	No
17. Boils and leg sores			Yes 3	No
18.Very slow wound healing			Yes 3	No
19. Excessive weight gain			Yes 3	No

PART 5 - Section B

PART 6 - Section A

1. Weakness and fatigue	0	1	2	3
2. Chest discomfort, pain	0	1	2	3
3. Sudden breathing difficulty	0	1	2	3
4. Shortness of breath	0	1	2	3
5. Shallow breathing	0	1	2	3
6. Noisy rattling sounds when breathing in and out	0	1	2	3
7. Cough-dry or moist	0	1	2	3
8. Rapid heartbeats	0	1	2	3
9. Excessive perspiration	0	1	2	3
10. Anxiety, restlessness	0	1	2	3
11. Consistent low grade temperature (100 -101)	0	1	2	3
12. Bluish nails and lips	0	1	2	3
13. Post nasal drip	0	1	2	3
14. Sputum - thick, clear, yellow	0	1	2	3
15. Sputum - smells offensive	0	1	2	3
16. Bloody sputum	0	1	2	3
17. Bad breath	0	1	2	3
18. Wheezing	0	1	2	3
19. Loud snoring	0	1	2	3
20. Sleepy during day	0	1	2	3
21. Morning headache	0	1	2	3
22. Difficulty concentrating	0	1	2	3
23. Unexplained weight loss			Yes 3	No
24. Infections settle in lungs			Yes 3	No
25. Flu symptoms last longer than 5 days			Yes 3	No

PART 6 - Section A

PART 7 - Section A

1. Retain fluid throughout body	0	1	2	3
2. Mild lower back pain	0	1	2	3
3. Frequent urge to urinate, but only small amounts pass	0	1	2	3
4. Interruption of urine stream	0	1	2	3
5. Excessive urination	0	1	2	3
6. Excessive urination at night	0	1	2	3
7. Burning when urinating	0	1	2	3
8. Frequent urination with urgency	0	1	2	3
9. Rarely need to urinate	0	1	2	3
10. Difficulty passing urine	0	1	2	3
11. Dripping after urination	0	1	2	3
12. Can't hold urine	0	1	2	3
13. Bloody, cloudy and/or darkened urine	0	1	2	3
14. Strong smelling urine	0	1	2	3
15. Joint and muscle pain	0	1	2	3
16. Tingling in joints	0	1	2	3
17. Dark circles under eyes	0	1	2	3
18. Grey, blackish caste to skin	0	1	2	3
19. Back or leg pains associated with dripping after urination			Yes 5	No
20. Poor skin elasticity, dryness			Yes 3	No

PART 7 - Section A

PART 8: Section A (MALES ONLY)

1. Frequent or urgent need to urinate	0	1	2	3
2. Delayed, weak, or interrupted urinary stream	0	1	2	3
3. Pain or burning upon urination	0	1	2	3
4. Urge to urinate several times a night	0	1	2	3
5. Rose colored (bloody) urine	0	1	2	3
6. Difficulty urinating	0	1	2	3
7. A sense of bladder fullness	0	1	2	3
8. Ejaculation causes pain	0	1	2	3
9. Blood in the semen	0	1	2	3
10. Lack of sex drive	0	1	2	3
11. Impotency	0	1	2	3
12. Pain or fatigue in the legs or back	0	1	2	3
13. Dripping after urination	0	1	2	3
14. Increased straining with small amounts of urine passed	0	1	2	3
15. Anemia			Yes 3	No

PART 8 - Section A

PART 8 - Section B (MALES ONLY)

1. Itchy patches around inner thigh and groin	0	1	2	3
2. Itching at night	0	1	2	3
3. Painful testicles	0	1	2	3
4. Difficulty attaining and/or maintaining an erection	0	1	2	3
5. Low sexual drive	0	1	2	3
6. Premature ejaculation	0	1	2	3
7. Low energy level or stamina	0	1	2	3
8. Inflammation on the head of penis			Yes 5	No
9. Genital and/or rectal rash or irritation			Yes 5	No
10. Distorted nail growth			Yes 3	No
11. Loss of pubic or armpit hair			Yes 3	No
12. Infertile			Yes 3	No
13. Low sperm count, low sperm motility			Yes 3	No
14. Unexplained weight gain			Yes 3	No
15. Testicles appear smaller			Yes 3	No
16. Development of breasts or nipple tenderness			Yes 3	No
17. Feeling of heaviness or hardness in testicles			Yes 3	No
18. Sparse beard or slow hair growth			Yes 3	No
19. Decreased body hair			Yes 3	No
20. Fine wrinkling in corner of mouth or around eyes			Yes 3	No

PART 8 - Section B

Part 9 - Section A (Females Only)

1. Insomnia	0	1	2	3
2. Abdominal bloating	0	1	2	3
3. Breast tenderness, swelling	0	1	2	3
4. Breast lumps appear	0	1	2	3
5. Heart palpitations	0	1	2	3
6. Sweating and flushing	0	1	2	3
7. Depressed. irritable, nervous	0	1	2	3
8. Easy to anger, resentful	0	1	2	3
9. Easily overwhelmed	0	1	2	3
10. Nausea and/or vomiting	0	1	2	3
11. Diarrhea or constipation	0	1	2	3
12. Headache	0	1	2	3
13. Food cravings, binge eating	0	1	2	3
14. Back pain	0	1	2	3
15. Feel faint	0	1	2	3
16. Clumsiness	0	1	2	3
17. Forgetful	0	1	2	3
18. Weight gain - water			Yes 3	No
19. Suicidal			Yes 10	No

PART 9 - Section A

PART 9 - Section B (FEMALES ONLY)

1. Vaginal dryness, pain	0	1	2	3
2. Painful intercourse	0	1	2	3
3. Engorged breasts	0	1	2	3
4. Milk production (not nursing)	0	1	2	3
5. Disinterest in sex	0	1	2	3
6. Blurred vision	0	1	2	3
7. Headache	0	1	2	3
8. Acne and/or oily skin	0	1	2	3
9. Aggressive feelings	0	1	2	3
10. Overwhelming urges for sexual intercourse	0	1	2	3
11. Absence of menstrual flow for six or more months			Yes 20	No
12. Occasionally skip periods			Yes 5	No
13. Menstruation began after 16 years old			Yes 3	No
14. Breasts shrinking			Yes 5	No
15. Thinning pubic and armpit hair			Yes 5	No
16. Unable to get pregnant			Yes 10	No
17. Miscarriage			Yes 3	No
18. Excess facial hair			Yes 5	No
19. Poor sense of smell			Yes 3	No
20. Monthly abdominal pain without bleeding			Yes 5	No

PART 9 - Section B

PART 9 - Section C (FEMALES ONLY)

1. Painful intercourse	0	1	2	3
2. Menstrual type pain between menses	0	1	2	3
3. Irregular time intervals between periods			Yes 5	No
4. Extended menses greater than 32 days			Yes 10	No
5. Shortened menses (less than every 24 days)			Yes 5	No
6. Vaginal bleeding between periods			Yes 10	No
7. Vaginal discharge between periods			Yes 5	No
8. Pain during periods is getting progressively worse			Yes 5	No
9. Pain, cramps	0	1	2	3
10. Unusual fatigue; can't work	0	1	2	3
11. Irritable and depressed	0	1	2	3
12. Constipation and/or diarrhea	0	1	2	3
13. Lower abdominal pain, bloating	0	1	2	3
14. Nausea and/or vomiting	0	1	2	3
15. Lower backache	0	1	2	3
16. Pelvic and/or rectal pressure	0	1	2	3
17. Urinary difficulties	0	1	2	3
18. Frequent urination			Yes 5	No
19. Scanty blood flow			Yes 3	No
20. Heavy blood flow			Yes 3	No

PART 9 - Section C

PART 9 - Section D (FEMALES ONLY)

1. Lumps are painful, tender