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Health Assessment QuestionnairePlease complete as clearly Essay

Paper type: Assessment Pages: 7 (1749 words)

Views: 389

Health Assessment Questionnaire

Please complete as clearly, completely and accurately as possible

(don’t worry if there are some details you don’t know). Then return,

at least two days before your consultation by e-mail to [email protected]

If you do not have e-mail then please call 6477047578 to ask where it should be posted.

PRIVATE AND CONFIDENTIAL

ETAILS

Title: …………. First Name: ………………………………………………… Last Name: ………………………………………………………….

Address: ………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………… Post Code: …………………..

Phone Numbers: …………………………………………………………………………………… Email: ……………………………………………

Date of Birth: ……………………………………………. Age: ……………. Occupation: …………………………………………………………

Marital status: Children:

Is your GP aware you are having nutritional therapy? (Y/N)

Do you give your permission for your GP to be contacted? (Y/N)

GP’s Name: ………………………………………………… Address: ……………………………………………………………………………

………………………………………………………………………………………………………………………………… Post Code: …………………

What is your main reason for seeking nutritional advice? …………………………………………………………………………………….

List the outstanding health problems you have in the order of importance and indicate how long you have had them

(Use a separate sheet if necessary):

Health Problem Duration

1.

2.

3.

4.

5.

Under what circumstances do these problems get worse?

Under what circumstances do they improve?

CAN YOU TRACE THE ORIGIN OF ANY PRESENT CONDITION TO ANY PARTICULAR

CIRCUMSTANCE? (e.g. accident, illness, grief, mental upset etc.)

ANY SERIOUS SHOCK, GRIEF, DISAPPPOINTMENT, FRIGHT, DEPRESSION, ETC.?

List any major surgery or significant periods of ill health in your life and any chronic or niggling health problems:

Give details (date, reason) of any antibiotic use in the past 12 months?

HAVE YOU EVER SUFFERED FROM ANY OF THE FOLLOWING CONDITIONS?

Please circle any that apply:

Abscesses, Anemia, Arthritis, Asthma, Cancer, Chicken Pox, Cold Sores, Diabetes, Eczema, Emphysema,

Epilepsy, Frequent Colds, Gallstones, Genital Herpes, Gonorrhea, Gout, Heart Disease, Hepatitis, HIV,

Influenza, Kidney Disease, Leukemia, Lyme disease, Malaria, Measles, Mononucleosis, Mumps, Parasites,

Pelvic Inflammatory Disease, Peritonitis, Pleurisy, Pneumonia, Prostatitis, Psoriasis, Rheumatic Fever,

Rubella, Scarlet Fever, Sexual Abuse, Skin Diseases, Sinusitis, Strep Throat, Stroke, Sunstroke, Syphilis,

Tonsillitis, Tuberculosis, Typhoid Fever, Venereal Warts, Warts, Whooping Cough, Worms, Yellow Fever

Other:

PERSONALITY PROFILE

Many times your health can be influenced by your mental/emotional state. As an aid to help determine the best homeopathic remedy for you, please circle any of the following characteristics that describe you best.

Animated- Playful -Sociable -Convincing –Refreshing- Spirited –Promoter- Spontaneous

Optimistic -Funny –Delightful- Cheerful- Inspiring- Demonstrative -Mixes easily –Talker- Lively

Cut Popular- Bouncy- Brassy -Undisciplined -Repetitious -Forgetful -Interrupts -Unpredictable Haphazard -Permissive -Angered easily- Na?ve -Wants credit –Talkative- Disorganized Inconsistent -Show-off- Loud -Scatterbrained -Restless -Changeable –Adventurous- Persuasive Strong-willed- Competitive- Resourceful -Self-reliant -Positive -Sure –Outspoken- Forceful Daring- Confident- Independent- Decisive- Mover –Tenacious- Leader -Chief –Productive- Bold Bossy -Unsympathetic -Resistant –Frank- Impatient- Unaffectionate –Headstrong- Proud Argumentative -Nervy Workaholic-Tactless- Domineering- Intolerant- Manipulative -Stubborn Short-tempered -Rash -Crafty- Analytical -Persistent -Self-sacrificing -Considerate -Respectful Sensitive Planner-Scheduled –Orderly- Faithful -Detailed -Cultured -Idealistic -Deep- Musical Thoughtful –Loyal –Caretaker- Perfectionist- Behaved- Bashful -Unforgiving –Resentful- Fussy Insecure -Unpopular -Hard to please- Pessimistic -Alienated -Negative attitude -Withdrawn Too sensitive -Depressed -Introvert -Moody -Skeptical -Loner- Suspicious- Revengeful- Critical Adaptable -Peaceful –Submissive- Controlled -Reserved –Satisfied- Patient- Obliging- Friendly Diplomatic -Consistent -Inoffensive -Dry humour- Mediator- Tolerant –Listener- Contented Permissive- Balanced- Blank -Unenthusiastic -Reluctant –Fearful- Indecisive- Uninvolved Hesitant Plain -Aimless -Nonchalant –Worrier –Timid- Doubtful -Indifferent –Mumbles- Slow Lazy –Sluggish- Reluctant- Compromising

Please circle any of the following medications you are currently taking or have taken in the last month:

Antacids – Antibiotics – Anticonvulsants – Antidepressants – Antifungals

Aspirin or Ibuprofen – Asthma inhalers – Beta blockers – Chemotherapy – Cortisone /steroids

Diabetic medications – Diuretics – Estrogen/Progesterone – Heart medications

High blood pressure – Hormone Therapy – Laxatives – Insulin – Oral/implant contraceptives

Radiation exposure- Recreational drugs – Relaxants/Sleeping pills – Thyroid medication

Tylenol/acetaminophen – Ulcer medications

List any other prescribed medications you are currently taking (name and dose):

List any vitamins, minerals, herbs or other health supplements you might be taking:

Your weight: Height. Blood Pressure: Pulse Rate:

Please scan and attach /or bring with you to the consultation any test results or other investigations you has recently

Family Health Profile

FAMILY HEALTH PROFILE

If you have any brothers and sisters what illnesses are they prone to?

If you have any children what illnesses are they prone to?

Do/did your parents or grandparents suffer from any illnesses (e.g. heart disease, diabetes, asthma etc)? Give details:

Symptom Analysis

Please read through the symptoms listed in Personal Vitamin & Mineral Analysis (a separate file or sheet) and place a tick against any that you are presently aware of.

Life Style Analysis

LIFESTYLE ANALYSIS

Please read through the questions below and place a tick against any that apply to you.

Cardiovascular Profile

Is your blood pressure above 140/90?

Is your pulse after 15 minutes’ rest above 75?

Are you more than 14lbs (7kg) over your ideal weight?

Do you smoke more than 5 cigarettes a day?

Do you do less than 2 hours exercise a week?

Do you eat more than one spoonful of sugar a day?

Do you eat red meat more than 5 times a week?

Do you usually add salt to your food?

Do you have more than 2 alcoholic drinks a day?

Is there a history of heart disease in your family?

Do you experience dull pain or tightness in the chest?

Do you have any chest pain that radiates into the left arm?

Do you get short of breath easily after light exertion?

Air hunger” or yawn frequently?

Do you have a persistent night cough?

Are you aware of heart palpitations (rapid heartbeat)?

Do you have a puffy face or swollen ankles by the end of the day or retain water easily?

Do you or your parents have varicose veins?

Are your hands and feet always cold?

Exercise Profile

Do you take exercise that noticeably raises your heart rate for 20 minutes more than 3 times a week?

Does your job involve vigorous activity?

Do you regularly play a sport (football, squash etc)?

Do you have any physically tiring hobbies (gardening, cycling etc)?

How many times a week and how long do you exercise, if at all?

How much walking do you do every day?

Do you consider yourself fit?

Polllution Profile

Do you live in a city or by a busy road?

Do you spend more than 2 hours a week in traffic?

Do you exercise (jog, cycle, play sports) by busy roads?

Do you smoke? How many cigarettes a day?

Do you live or work in a smoky atmosphere?

Do you buy foods exposed to exhaust fumes?

Do you generally eat non-organic produce?

Do you drink more than 1 unit of alcohol a day?

Do you spend a lot of time in front of a TV or PC screen?

Do you use a microwave oven for your cooking and how often?

Do you usually drink unfiltered tap water?

Are you a frequent flyer? How many times a year do you travel by plane?

Are you exposed to any chemicals in the course of your work (hairdressing, painting, farming, etc.)?

How many amalgam fillings do you have in your mouth?

Stress Profile

Stress Profile

Do you tend to be a ‘night person’?

Do you feel guilty when relaxing?

Do you have a persistent need for achievement?

Are you unclear about your goals in life?

Are you especially competitive?

Do you work harder than most people?

Do you work more than 60 hours a week? (Usually, occasionally, never)

Do you easily become angry?

Have you gone through divorce fairly recently?

Have you changed jobs within the last year?

Have you lost any members of the family, close relatives or friends recently?

Do you often do 2 or 3 tasks simultaneously?

Do you get impatient if people or things hold you up?

Do you have difficulty getting to sleep?

Do you gain weight predominantly around your abdomen?

Do you crave salty foods?

Do you feel wired or jittery when drinking coffee?

Do you clench or grind your teeth?

Do you have dark circles under eyes?

Do you become dizzy when standing up suddenly?

Rate your stress level on the scale 0 – 10 (10 being the highest):

Nervous System Profile

Do you suffer from any sleep disturbances (waking at a particular time at night, night sweats, vivid or scary dreams)?

What is your sleep pattern (wake up or fall asleep easily / with difficulty, early, need more than 8 hrs sleep, light or heavy sleeper, etc)?

Do you suffer from headaches / migraines?

Do you have any visual disturbances (fuzzy, double or tunnel vision, etc.)

Do you suffer from dizziness / vertigo / weakness?

Are you prone to fainting or epileptic fits?

Do you have a sensation of ‘pins and needles’ or numbness in your hands or feet?

Are your emotions fairly stable?

Are you prone to sudden mood changes?

Are you an anxious person?

Is your long term memory bad?

Is you short term memory bad?

Is your concentration bad?

Emotional Profile

Do you have panic attacks?

Do you have particular fears or phobias (spiders, illness, losing a job, etc.)?

Are you a shy person?

Do you feel like your mind is over-strained and you are going to explode or do irrational things?

Are you overly anxious about other people including your loved ones and worry about bad thngs happening to them?

Are you very critical of others and find them difficult to accept them as they are? (a bit intolerant)

Do you spend a lot of time and energy trying to convert people to your way of thinking?

Do you wash your hands obsessively? Do you find something ‘unclean’ about yourself?

Are you prone to circular or repetitive thinking when it’s hard to switch off (cluttered head)?

Are you impatient and often want things done faster? Or frustrated with other people being slow?

Are you a high achiever, often overwork and ignore your tiredness?

Do you feel overwhelmed by work or life situations to the point of being depressed and exhausted?

Have you suffered a misfortune that you find difficult to accept and feel sulky, grumpy and sorry for yourself?

Are you easily discouraged and disheartened?

Do you have bouts of sudden gloom or depression for no apparent reason (‘dark cloud’)?

Are you a jealous person?

Are you calm or cheerful on the outside but troubled inside? (Successfully hiding your feelings)

Are you tormented by fear that something bad is going to happen but can’t say what exactly? (Vague fear)

Are you a ‘push-over’ and easily neglect your own needs for those of others?

Do you lack confidence to make your own decisions and need advice and approval of others?

Do you tend to make the same mistakes over and over again?

Are you a day-dreamer, living more in the future than in the present?

Do you tend to be quite possessive with those people you care about?

Do you dislike being alone and always need company of others?

Do you pine after the ‘good old days’ and live in the past?

Do you feel that whatever you do you are unlikely to succeed and give up easily?

Is daily life a hard work for you without any pleasure? (Feeling physically or mentally exhausted)

Do you tend to blame yourself for anything that goes wrong?

Do you prefer to be alone and go about your own business?

Glucose Tolerance Profile

Awaken a few hours after falling asleep, hard to get back to sleep?

Do you need more than 8 hours sleep a night?

Are you rarely wide awake within 20 minutes of rising?

Do you need something to get you going in the morning, like a tea, coffee or cigarette?

Do you have tea, coffee, sugary foods or drinks, or cigarettes at regular intervals during the day?

Cite this page

Health Assessment QuestionnairePlease complete as clearly. (2019, Nov 26). Retrieved from https://studymoose.com/health-assessment-questionnaireplease-complete-as-clearly-best-essay

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