Health Appraisal Questionnaire

 

Referring Practitioner 











Page 1

 First Name:
 Last Name:
 Street:
 Town:
 State:
 Postcode:
 Phone:
 Email:
 Date of Birth: 
Male
Female

Select the word that best
suits your symptoms, in either Severity or Frequency. i.e:

Mild and or Infrequent Symptoms (twice per week or less)

Moderate and or Frequent Symptoms (3 to 6 times a weekly)

Severe and or Daily Symptoms

Section 1. 

1.Curved spine,height loss,stooped
base of neck(dowager’s hump)


2. Bone pain, back, hip
or knee pain


3. Spinal problems, pain, Sciatic pain


4. Osteoporosis


5. Recent broken bones,
fractures


6. Osteoarthritis / rheumatoid
arthritis


7. Joints swelling
painful, deformity, injury, stiffness


8. Noisy joints (creak,
grind etc.)


9. Nodules on fingers


10. High uric acid on blood
testing


11. Damaged disc, slipped
disc


12. Bursitis or tendonitis


 

Section 2.

1. Tightness or pain in
back, neck or shoulder muscles


2. Muscular spasms


3. Spinal problems, pain,
Sciatic pain


4. Stiffness in muscles


5. Tenderness, pain in muscles


6. Weakness in muscles


7. Trembling (fasiculation)


Section 3.

1. Chest tightness on stress or exertion


2. Palpitations, arrythmias, extra beats


3. Swelling of the ankles


4. Shortness of breath on exertion/rest


5. Calf pain on exercise


6. Dizziness on exertion


7. Previous angina attacks, heart attack or stroke
8. Known cardiac murmur or condition
9. High blood cholesterol, triglycerides or blood clotting problems
10. Blood Pressure or Heart medication

Section 4.

1. Blue, numb, cold fingers or toes
2. Ulcers, sores on legs and feet
3. Shiny, discoloured, hairless skin on arms or legs / Varicose veins
4. Cramps, pain in legs when walking


5. Pins and needles, numbness – hands, feet


6. Fluid retention feet, legs, body


7. Difficulty with written or spoken words or concentration


8. Dizzyness, ringing in the ears


9. Fleeting nausea / Hearing loss


10. Previous deep vein thrombosis


11. Take Anti-clotting medication

Section 5.

1. Morning headaches


2. Feel tired, nervy, weak


3. Ringing in ears / Sleepy, dizzy


4. Hi Blood Pressure / Heart medication
5. Flushing with no known cause


6. Tingling and numb hands and feet


7. Blurry vision


Section 6.

1. Smoker
2. Cough


3. Asthma, Wheezing


4. Repeated chest infections


5. Shortness of breath on effort or at rest


6. Chest pain on breathing or coughing


7. Gets chest infections easily


8. Coughing up mucus/phlegm


9. Takes asthma medication

Section 7.

1. Burping up gas


2. Bloating after meals


3. Abdominal distention, swelling


4. Less than 1 bowel movement per day


5. Food intolerances, allergies


6. Foul smelling breath


7. Low vitamin B12 levels
8. Acne or Acne Rosacea


9. Eczema


10. Flaking, peeling or brittle nails


Section 8.

1. Past duodenal
ulcers, stomach problems
2. Do you have an ulcer
now ?
3. Do you use antacids
4. Stomach pains on lying
down or bending after a meal


5. Stomach symptoms, heartburn,
pain with stress or eating


6. Food, drink makes stomach
feel better


7. Black stools blood


8. HB Breath
Test positive

Section 9.

1. Abdominal
cramps after eating meals


2. Abdominal cramps opening
bowels


3. Loose stools, constipation


4. Tiredness after meals


5. Smelly stools


6. Acne, Food allergies


7. Inflammation of the small
bowel


8. Mucous in stools


 9. Fullness, indigestion
for 2-4 hrs after meals


10. Flatulence
(bowel gas, farting)


Section 10.

1. Chronic fungal
infections, thrush, parasites abnormal bacteria


2. Low fibre diet


3. Constipation, diarrhoea,
colitis


4. Antibiotic use (note
frequency)


5. High meat intake


6. Abdominal bloating /
distention


7. Flatulence (farting)


8. Abdominal pain


9. Changeable bowel habits


10. Red blood
in stool  (or blood found in stool on testing)