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

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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 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
0 1 2 3
2. Tingling sensation in hands 0 1 2 3
3. Palpitations 0 1 2 3
4. Feel shaky, jittery, tremors 0 1 2 3
5. Weakness 0 1 2 3
6. Profuse perspiration, clammy 0 1 2 3
7. Nightmares 0 1 2 3
8. Awake from sleep restless 0 1 2 3
9. Agitated, easily upset, nervous 0 1 2 3
10. Poor memory, forgetful 0 1 2 3
11. Confusion, disoriented 0 1 2 3
12. Dizziness, feel faint 0 1 2 3
13. Feeling cold, numbness 0 1 2 3
14. Mild headaches 0 1 2 3
15. Blurred or double vision 0 1 2 3
16. Lack of coordination 0 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
0 1 2 3
2. Clear, gray, or yellow vaginal discharge 0 1 2 3
3. Vaginal bleeding after sex or between periods 0 1 2 3
4. Burning or itching of external genitalia 0 1 2 3
5. Urgent, painful urination 0 1 2 3
6. Lower abdominal or back pain 0 1 2 3
7. Heavy, watery and bloody vaginal discharge 0 1 2 3
8. Heavy menstrual flow 0 1 2 3
9. Pelvic cramps 0 1 2 3
10. Thin, scant, white vaginal discharge 0 1 2 3
11. Greenish, yellow, or offensive discharge 0 1 2 3
12. Cheesy white discharge 0 1 2 3
13. Breast lumps or swelling     Yes 10 No
14. Lumps hurt just before period     Yes 5 No
15. Swelling under armpit     Yes 5 No
16. Change in breast size, shape     Yes 5 No
17. White or slightly bloody vaginal discharge, one week prior to period     Yes 10 No
PART 9 - Section D

PART 9 - Section E (FEMALES ONLY)
1. Irregular menstrual cycle
0 1 2 3
2. Dry skin, hair, vagina 0 1 2 3
3. Disinterest in sex 0 1 2 3
4. Mood swings, irritable 0 1 2 3
5. Depression, anxiety, nervousness 0 1 2 3
6. Craving for sweets, binge eating 0 1 2 3
7. Headaches or dizziness 0 1 2 3
8. Painful intercourse 0 1 2 3
9. Sudden hot flashes 0 1 2 3
10. Spontaneous sweating 0 1 2 3
11. Shortness of breath and/or heart palpitations 0 1 2 3
12. Unpredictable vaginal bleeding 0 1 2 3
13. Difficulty holding urine 0 1 2 3
14. Difficulty sleeping 0 1 2 3
15. Mental fogginess 0 1 2 3
16. Vaginal pain and/or itching 0 1 2 3
17. Thin, scant white vaginal discharge 0 1 2 3
18. Low back and/or hip pain 0 1 2 3
19. Breast tenderness, pain or tingling, pricking sensation 0 1 2 3
20. Easy bruising, loss of skin tone 0 1 2 3
21. Thinning armpit and pubic hair     Yes 5 No
22. Stopped menstruating     Yes 20 No
23. Breasts beginning to shrink, sag     Yes 10 No
24. Abnormal growth of hair above lip     Yes 3 No
PART 9 - Section E

PART 10 - Section A
1. Generalized bone tenderness and achiness
0 1 2 3
2. Localized bone pain 0 1 2 3
3. Bone deformity or swelling 0 1 2 3
4. Shins hurt during or after exercises 0 1 2 3
5. Low back or hip pain 0 1 2 3
6. Difficulty sitting straight 0 1 2 3
7. Limp, walking difficulties 0 1 2 3
8. Crunching or creaking sounds when move joints 0 1 2 3
9. Hands, feet, throat spasm or feel numb 0 1 2 3
10. Joint pain and stiffness - especially spine, hips, knees 0 1 2 3
11. Hearing loss, headaches, ringing in ears 0 1 2 3
12. Cavities     Yes 5 No
13. Tooth loss due to gum disease     Yes 5 No
14. Established bone loss     Yes 10 No
15. Calcium deposits     Yes 5 No
16. Spinal curvature     Yes 10 No
17. Recent loss of height     Yes 10 No
18. Bow legs     Yes 5 No
19. Stooped posture     Yes 5 No
20. Hump at base of neck     Yes 5 No
21. Irregular patches of increased pigmentation     Yes 3 No
22. Unexplained bone fracture     Yes 10 No
PART 10 - Section A

PART 10 - Section B
1. Muscle aches and pains
0 1 2 3
2. Muscle stiffness, tension 0 1 2 3
3. Specific points on body feel sore when pressed 0 1 2 3
4. Headaches 0 1 2 3
5. Fatigue, tired, sluggish 0 1 2 3
6. Difficulty sleeping 0 1 2 3
7. Feel unrefreshed upon awakening 0 1 2 3
8. Difficulty speaking/swallowing 0 1 2 3
9. Muscle cramps or spasm 0 1 2 3
10. Muscles twitch or tremble - eyelids, thumb, calf muscle 0 1 2 3
11. Irresistible urge to move legs 0 1 2 3
12. Legs move during sleep 0 1 2 3
13. Unpleasant crawling sensation inside the calves, while lying down 0 1 2 3
14. Numbing, tingling sensation 0 1 2 3
15. Excessive joint mobility 0 1 2 3
16. Unable to fully straighten or extend legs and/or arms 0 1 2 3
17. Upper or lower back pain 0 1 2 3
18. Loss of muscle strength     Yes 3 No
19. Muscle loss, wasting     Yes 3 No
PART 10 - Section B

PART 10 - Section C
1. Joint stiffness, soreness, swelling 0 1 2 3
2. Red, swollen painful joints 0 1 2 3
3. Joint stiffness improves when resting, worsens with movement 0 1 2 3
4. Dry mouth 0 1 2 3
5. Dry painful eyes 0 1 2 3
6. Joint stiffness worsens with rest, improves with movement 0 1 2 3
7. Cracking joints 0 1 2 3
8. Limp 0 1 2 3
9. Shooting, aching, tingling pain down the back of leg 0 1 2 3
10. Joint pain involves one or a few joints 0 1 2 3
11. Joints hurt when moving or when carrying weight 0 1 2 3
12. Limited range of motions 0 1 2 3
13. Difficulty standing up 0 1 2 3
14. Walks slowly 0 1 2 3
15. Headache 0 1 2 3
16. Difficulty chewing food or opening mouth 0 1 2 3
17. Intermittent pain, ache on one side of head spreading to cheek, temple, lower jaw, ear, neck and shoulder 0 1 2 3
18. Numbness, prickling, tingling sensation in the neck, shoulder and arms 0 1 2 3
19. Injure, strain, sprain easily 0 1 2 3
20. Discomfort or pain in neck, shoulder or arm 0 1 2 3
21. Involuntary muscle spasms 0 1 2 3
22. Deliberate movement with hands are difficult 0 1 2 3
23. Red painless skin lumps on elbows, knees, toes, ear, nose, back of scalp     Yes 5 No
24. Knobby overgrowths on the joints closest to the fingertips     Yes 5 No
25. Muscle loss around inflamed joint     Yes 10 No
26. Double jointed     Yes 3 No
27. One leg shorter than the other     Yes 5 No
PART 10 - Section C

PART 10 - Section D
1. Head feels heavy 0 1 2 3
2. Light-headed/fainting 0 1 2 3
3. Ringing/buzzing in ears 0 1 2 3
4. Trembling hands 0 1 2 3
5. Limbs feel too heavy to hold up 0 1 2 3
6. Loss of feeling in hands and/or feet (toes) 0 1 2 3
7. Tingling, followed by numbness or pain; begins in hands and feet, spreads toward center of body 0 1 2 3
8. Unsteady gait, lose balance 0 1 2 3
9. Muscles feel weak 0 1 2 3
10. Weak grip with spasm and arm weakness 0 1 2 3
11. Exhaustion on slightest effort 0 1 2 3
12. Need for 10-12 hours sleep 0 1 2 3
13. Muscular weakness begins in leg and moves upward 0 1 2 3
14. Difficulty walking, moving around, handling small objects 0 1 2 3
15. Nervous, anxious 0 1 2 3
16. Convulsions 0 1 2 3
17. Confused, forgetful 0 1 2 3
18. Slowed or slurred speech 0 1 2 3
19. Difficulty breathing 0 1 2 3
20. Blurred vision 0 1 2 3
21. Eyelids droop 0 1 2 3
22. Impaired hearing, eyesight, sense of touch, smell, taste     Yes 10 No
23. Accident prone: trip, stumble, feel clumsy     Yes 5 No
PART 10 - Section D

Copyright, 1995 Lyra Heller and Michael Katke