Naturopath Health Appraisal

NAME: Surname: DATE:

SELECT the number which best describes the frequency of your symptoms. If you do not know the answer to the question, leave it blank. The score for YES is the number inside the parenthesis ( ).

0 = never or rarely 1 = twice a week or less 2 = three to six times a week 3 = daily or several times a day

PART I       GASTROINTESTINAL


Section A - HYPOACIDITY

1. Indigestion
2. Belching, burping
3. Gas immediately following a meal
4. Sense of fullness during meals
5. Poor appetite, picky eater
6. Difficult bowel movements
7. Difficulty swallowing
8. History of anaemia, unresponsive to iron
9. Vegetarian (no eggs, dairy)
10. Spoon shaped nails
11. Unintentional weight loss
12. Partial loss of taste or smell

Total Points


Section B - SMALL INTESTINE / PANCREAS

1. Indigestion and fullness lasts 2-4 hours after eating
2. Pain, tenderness, soreness on left side under rib cage
3. Bloated
4. Excessive passage of gas
5. Abdominal cramps, aches
6. Nausea and / or vomiting
7. Specific foods / beverages aggravate indigestion
8. Roughage and fibre cause constipation
9. Three or more large bowel movements daily
10. Alternating constipation and diarrhoea
11. Undigested food in stool
12. Mucus in stool
13. Dry, flaky skin; dry, brittle hair
14. Difficulty gaining weight

Total Points


Section C - HYPERACIDITY

1. Stomach pain, burning, aching,1-4 hours after eating
2. Feeling hungry an hour or two after eating
3. Stomach discomfort, pain in response to strong emotions, thoughts, smell of food
4. Heartburn, especially whenlying down or bending forward
5. Heartburn due to spicy and fatty foods,chocolate, peppers, citrus, alcohol, caffeine
6. Difficulty or pain when swallowing
7. Chest pain or infections, difficulty breathing
8. Carbonated beverages, cream / milk / food give temporary relief from symptoms
9. Constipation
10. Black, tarry stool

Total Points


Section D - COLON

1. Lower abdominal pain, cramping and / or spasms
2. Lower abdominal pain, relief by passing stool or gas
3. Raw fruits, vegetables and stress aggravate bowel pain
4. Diarrhoea (loose watery stool)
5. More than three bowel movements daily
6. Excessive gas and bloating
7. Painful, difficult, straining during bowel movements
8. Hard, dry or small stool
9. Extremely narrow stools
10. Alternating diarrhoea / constipation
11. Mucus, pus in stool
12. Feel bowels do not empty completely
13. Bright red blood following bowel movement
14. Anal itching

Total Points

PART II   DETOX METABOLISM


Section A - LIVER / GALLBLADDER / PANCREAS

1. Moderate to severe pain under right side of ribcage
2. Abdominal pain worsens with deep breathing
3. Regurgitate bitter fluid
4. Bloated, full feeling
5. Belching, heartburn, gas
6. Fatty foods cause indigestion
7. Nausea or vomiting
8. Feel restless, agitated, angry
9. Unexplained itchy skin, worse at night
10. Stool colour alternates from clay colour to normal brown
11. Feeling of poor health
12. Fatigue, weakness, exhaustion
13. Unable to concentrate, irritable, confused
14. Swollen feet and / or legs
15. Easy bruising
16. Feeling of extreme dryness
17. Reddened skin, especially palms
18. Dark urine, diminished flow
19. Dry, flaky skin, hair
20. Yellowish cast to skin, eyes

Total Points


Section B - HYPOTHYROID

1. Fatigued, sluggish
2. Feel cold - hands, feet
3. Difficult, infrequent bowel movements
4. Dryness of skin, hair
5. Thick, brittle nails
6. Outer third of eyebrow thins
7. Puffy face, hands and feet
8. Swollen upper eyelids
9. Eyeballs move involuntarily
10. Muscles weak, cramp and / or tremble
.11. Slow mental processes, forgetfulness
12. Slow heart beats
13. Loss of appetite
14. Abdominal swelling
15. Unsteady gait, movements
16. Lack of interest in sex
17. Premenstrual tension
18. Infertility
19. Heavy menstrual bleeding
20. Gain weight easily
21. Swelling of the neck
22. Thinning hair on scalp, face and genitals

Total Points

PART III     IMMUNE FUNCTION

1. Progessive, mild fatigue after exertion or stress
2. General weakness
3. Blurred vision, dizzy when rising
4. Depression
5. Rapid mood swings
6. Irritable, nervous
7. Dark circles under the eyes
8. Disinterest in food
9. Abdominal pain
10. Indigestion
11. Blotchy skin (white patches)
12. Tan skin, no sun
13. Black freckles on upper forehead,face, neck
14. Craving for salty foods
15. Gradual loss of body hair
16. Sensitive to minor changes in weather and surroundings

Total Points

PART IV       MUSCULOSKELETAL


Section A - BONE INTEGRITY

1. Generalised bone tenderness and achiness
2. Localised bone pain
3. Bone deformity or swelling
4. Shins hurt during or after exercise
5. Low back or hip pain
6. Walking difficulties, limp
7. Crunching or creaking sounds when moving joints
8. Hands, feet, throat spasm or feel numb
9. Joint pain and stiffness -especially spine, hips, knees
10. Hearing loss, headaches, ringing in ears
11. Established bone loss.
12. Calcium deposits
13. Spinal curvature
14. Recent loss of height
15. Bow legs
16. Stooped posture
17. Hump at base of neck
18. Unexplained bone fracture
19. Tooth loss, gum disease

Total Points


Section B - MUSCLE

1. Generalised muscle aches and pains
2. Localised muscle stiffness, tension, pain
3. Specific body points feel sore when pressed
4. Headaches
5. Fatigued, tired, sluggish
6. Difficulty sleeping
7. Feel unrefreshed upon waking
8. Muscle weakness or loss
9. Difficulty speaking / swallowing
10. Muscle cramps or spasm
11. Muscles twitch or tremble - eyelids, thumb, calf muscle
12. Irrestible urge to move legs
13. Legs move during sleep
14. Legs move during sleep
15. Excessive joint mobility
16. Unable to fully straighten or extend legs and / or arms
17. Upper or lower back pain

Total Points


Section C - CONNECTIVE TISSUE

1. Joint stiffness, soreness
2. Red, swollen, painful joints
3. Joint stiffness improves with rest, worsens with movement
4. Cracking joints
5. Shooting, aching, tingling pain down the back of leg
6. Joint pain involves one or a few joints
7. Joints hurt when moving or when carrying weight
8. Limited range of motion
9. Difficulty standing up from seated position
10. Joint stiffness worsens with rest, improves with movement
11. Headache
12. Difficulty chewing food or opening mouth
13. Numbness, prickling, tingling sensation in the neck, shoulder and arms
14. Involuntary muscle spasms
15. Deliberate movement with hands is difficult
16. Injure, strain, sprain easily
17. Discomfort or pain in neck, shoulder or arm
18. Knobby overgrowths on the joints closest to the fingertips
19. Double jointed
20. One leg shorter than the other

Total Points

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