Health Assessment Form (Page 2 of 2) in pdf

Health Assessment Form

Section Four Continued:

Section Nine (Female Only)

58. Weakness after colds/slow recovery

Y or N

103. Premenstrual tension

Y or N

59. Circulation is poor

Y or N

104. Painful menses (cramping etc.)

Y or N

60. Muscular and nervous exhaustion

Y or N

105. Menstruation excessive or prolonged

Y or N

61. Allergies and / or hives

Y or N

106. Painful / tender breasts

Y or N

62. Arthritic tendencies

Y or N

107. Menstruate too frequently

Y or N

63. Nails weak, ridged

Y or N

108. Acne, worse at menses

Y or N

64. Perspire easily

Y or N

109. Depressed feelings before menstruation

Y or N

65. Slow starter in the morning

Y or N

110. Vaginal discharge

Y or N

66. Afternoon headaches

Y or N

111. Menses scanty or missed

Y or N

Section Five

112. Hysterectomy / ovaries removed

Y or N

67. Sex drive increased

Y or N

113. Menopausal hot flashes

Y or N

68.. “Splitting” type headache

Y or N

114. Depression

Y or N

Section Ten (Men Only)

70. Tolerance to sugar reduced

Y or N

71. Sex drive reduced or absent

Y or N

115. Prostate trouble

Y or N

72. Abnormal thirst

Y or N

116. Urination difficult or dribbling

Y or N

73. Weight gain around hips or waist

Y or N

117. Night urination frequent

Y or N

74. Tendency to ulcers or colitis

Y or N

118. Pain on inside of legs or heels

Y or N

75. Increased ability to eat sugar without symptoms

Y or N

119. Feeling of incomplete bowel evacuation

Y or N

76. Menstrual disorders (women)

Y or N

120. Leg nervousness at night

Y or N

77. Lack of menstruation (young girls)

Y or N

121. Tire easily / avoid activity

Y or N

Section Six

122. Reduced sex drive

Y or N

78. Difficulty gaining weight, even if large appetite

Y or N

123. Depression

Y or N

79. Heart palpitations

Y or N

124. Migrating aches and pains

Y or N

80. Nervous, emotional and / or can’t work under pressure

Y or N

81. Insomnia

Y or N

82. Inward Trembling

Y or N

83. Night Sweats

Y or N

84. Fast pulse at rest

Y or N

85. Intolerant to high temperatures

Y or N

86. Easily flushed

Y or N

Section Seven

87. Difficulty losing weight

Y or N

88. Reduced initiative and / or mental sluggishness

Y or N

89. Easily fatigued, sleepy during the day

Y or N

90. Sensitive to cold, poor circulation (cold hands & feet)

Y or N

91. Dry or scaly skin

Y or N

92. “Ringing” in ears/noises in head

Y or N

93. Hearing impaired

Y or N

94. Constipation

Y or N

95. Excessive hair falling out and / or coarse hair

Y or N

96. Headaches when awaken / wear off during day

Y or N

Section Eight

97. Blood pressure increased

Y or N

98. Headaches

Y or N

99. Hot flashes

Y or N

100. Hair growth on face or body (Question for Females)

Y or N

101. Masculine tendencies (Question to Females)

Y or N

102. “Air hunger” and / or Sigh frequently

Y or N

Health Assessment Form Page 2

Related Articles

Related forms

Related Categories