CIRCLE the number which best describes the frequency of your

HEALTH APPRAISAL – COMPREHENSIVE
NAME:
DATE:
CIRCLE the number which best describes the frequency of your symptoms. If you do not know the answer to the
question, leave it blank. When you are finished, please add the number of points in each section and enter the
number in the Total Points box. The score 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
PART 1
Section A
0.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Section C
Indigestion, “sour stomach”
Excessive belching, burping and/or bloating
Gas immediately following a meal
Sense of fullness during and after meals
Poor appetite, disinterest in food
Offensive breath
Bad taste in mouth
Partial loss of taste or smell
Difficult bowel movements
Difficulty swallowing
Unintentional weight loss
History of anemia, unresponsive to iron
Vegetarian (no eggs or dairy)
Picky eater
Spoon shaped nails
Sores in corner of mouth
Smooth tongue
0
0
0
0
0
0
0
0
0
0
N
N
N
N
N
N
N
1
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (5)
Y (5)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Total Points:
1.
Stomach pain, burning, aching
1-4 hours after eating
2. Feeling hungry an hour or two after eating
3. Strong emotions, thought or smell of
food aggravates stomach
4. Heartburn, esp. when lying 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, difficulty breathing, lung
Infections
8. Constipation, difficult bowel movements
9. Black, tarry stool
10. Unexplained weight gain
11. Temporary relief from antacids,
carbonated beverages, cream/milk/food
12. Digestive problems subside with rest
and relaxation
Section B
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Indigestion & fullness lasts
2-4 hours after eating
Pain, tenderness, soreness
On left side under rib cage
Bloated
Excessive passage of gas
Abdominal cramps, aches
Nausea and/or vomiting
Dry, flaky skin &/or dry brittle hair
Difficulty gaining weight
Weakness and fatigue
Specific foods/beverages
aggravate indigestion
Roughage and fiber causes constipation
Three or more large bowel
movements daily
Alternating constipation and diarrhea
Stool poorly formed
Stool – undigested food
Stool – greasy, shiny
Stool yellowish, foul smelling
Mucus in stool
Black stool
Rectal spasms
Dark urine
Bone and back pain
Pounding heart
Iron deficiency anemia
0
0
1
1
2
2
3
3
0
1
2
3
0
1
2
3
0
0
1
1
2
2
3
3
0
0
0
N
1
1
1
2
3
2
3
2
3
Y (3)
N
Y (3)
N
Y (3)
Total Points:
0
1
2
3
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
0
1
1
2
2
3
3
0
0
0
0
0
0
0
0
0
0
0
0
N
1
1
1
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (3)
Section D
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Lower abdominal pain, cramping
&/or spasms
Lower abdominal pain relief by passing
stool or gas
Raw fruits, veggies and stress aggravate
bowel pain
Diarrhea (loose watery stool)
More than 3 bowel movements daily
Excessive gas and bloating
Painful, difficult, straining during
bowel movements
hard, dry or small stool
Extremely narrow stools, thin stools
Alternating diarrhea/constipation
Mucus and pus in stool
Feeling that bowels don’t empty completely
Rectal pain or cramps
Bright red blood following
bowel movement
Anal itching
Irritable, moody
Rash under breast, armpit, around
naval or groin area
Feel ill in damp, moldy settings or rainy
weather
0
1
2
3
0
1
2
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
1
2
3
0
1
2
3
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Total Points:
Total Points:
PART II
Section A
1.
2.
3.
4.
Moderate to severe pain under right
side of rib cage
Abdominal pain worse with deep breathing
Bitter fluid repeats after eating
Bloated, full feeling
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
5.
6.
7.
8.
9.
10.
Belching, heartburn, gas
Fatty foods cause indigestion
Nausea
Feel restless, agitated, angry
Unexplained itchy skin worse at night
Yellowish cast to skin, eyes
0
0
0
0
0
0
11. Stool color alternates from clay colored to
normal brown
12. General feeling of poor health
13. Fatigue, weakness, exhaustion
14. Unable to concentrate, irritable, confused
15. Aching muscles
16. Trembling hands
17. Weight gain due to water retention
18. Swollen feet and/or legs
19. Bleeding tendencies in gums, nose
20. Loss of chest and armpit hair
21. Reddened skin, especially palms
22. Dark urine, diminished flow
23. Dry, flaky skin and/or hair
24. Loss of appetite and weight
25. Easy bruising
26. Thinning of pubic hair
27. Feeling extreme dryness
28. Loss of skin elasticity
29. Vomiting
Section B
0
0
0
0
0
0
0
0
0
0
0
0
N
N
N
N
N
N
N
1
1
1
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Total Points:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Tired, sluggish
Feel cold – hands, feet, all over
Tight sensation in neck
Difficult, infrequent bowel movements
Dryness, discoloration of skin &/or hair
Thick, brittle nails
Puffy face, hands and feet
Swollen upper eyelids
Eyeballs move involuntarily
Muscles weak, cramp &/or tremble
Slow mental processes, forgetfulness
Slow heartbeat
Abdominal swelling
Unsteady gait, movements
Lack of interest in sex
Gain weight easily
Swelling of the neck
Outer third of eyebrow thins
Thinning of hair on scalp, face and genitals
Loss of appetite
Premenstrual tension
Infertility
Excessive menstrual bleeding
Absence of periods
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
N
N
N
N
N
N
N
N
N
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (5)
Y (5)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Total Points:
PART III
Section A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Progressive, mild fatigue after exertion
or stress
General weakness
Blurred vision, dizzy when rising
Depression
Rapid mood swings
Irritable
Dark circles under eyes
Abdominal pain, indigestion
Bouts of nausea, vomiting
Diarrhea or constipation
Blotchy skin (white patches)
Craving for salty foods
Decreased appetite
Gradual weight loss
Tan skin, no sun
Gradual loss of body hair
Black freckles on upper forehead,
face, neck
Sensitive to minor changes in weather
and surroundings
0
0
0
0
0
0
0
0
0
0
0
0
N
N
N
N
1
1
1
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (3)
Y (3)
Y (3)
Y (3)
N
Y (3)
N
Y (5)
16.
17.
18.
19.
20.
21.
22.
23.
24.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Catch colds easily
Infections: eyes, ears, nose, throat,
lungs, skin
Diarrhea
Puffy face
Dark areas on cheeks, under eyes
Eyes tear, burn, discharge
Ears continuously drain
Nasal congestion or discharge: thick,
yellow, green
Sore throat or postnasal drip
Cough with mucus
Inflamed or bleeding gums
Cold sores, fever blisters
Gums swelling, bleeding
Unexplained weight loss of 10 pounds or
more in last three months
Lack of appetite
0
1
2
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
N
N
Y (5)
Y (3)
N
N
N
N
Y (5)
Y (3)
Y (3)
Y (3)
N
N
N
N
N
Y (5)
Y (3)
Y (3)
Y (5)
Y (5)
Total Points:
Section C
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Points:
Section B
Difficulty seeing at night
Nail discolorations
Bumpy skin on back of arms
Wounds heal slowly
Hair is easily plucked out, or falls out,
grows slowly
Lips are red and swollen
Tongue is red, swollen, raw looking
Impaired taste and smell
Neck, armpit, groin swelling
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Muscles fatigue quickly
Moody, irritable, tired
Severe fatigue
Severe joint pain, redness, swelling
Pain, stiffness throughout body
Migraine headaches
Sensitive to light (skin or eyes)
Dark circles under eyes
Swollen-looking face or body
Localized or general itching: eyes,
ears, throat, nose, skin
Clear, watery discharge from nose, eyes
Extreme dryness of eyes, nasal passages,
mouth
Sneezing
Cough or wheezing
Postnasal drip with certain foods
Heart palpitations after eating certain foods
Weight loss, muscle weakness
Scalp hair falls out easily, in clumps
Hair loss, entire body
Easy bruising
Nails – loosened, pitted, discolored
Specific food(s) worsen pain,
inflammation, stiffness
Moldy, damp environments
trigger sickness
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
0
0
1
1
2
2
3
3
0
0
0
0
0
N
N
N
N
N
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
Y (5)
Y (5)
Y (5)
Y (3)
Y (5)
N
Y (3)
N
Y (3)
Total Points:
PART IV
Section A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Sense of being overly tired
Prolonged recovery after exercise
Coldness, esp. in hands and feet
Difficulty breathing on exertion, palpitation
Headache, dizziness, spots before eyes
Irritable
Forgetful, poor concentration
Ringing in ears
Jaundice and dark urine
Black stool (no iron supplements)
Unusual cravings for clay, dirt, ice
Fingernails are flattened, spoonshaped,
brittle, thin
White patches on skin
Pale lips, gums, eyelids, nail beds
Red, sore tongue
Mouth, throat, rectum ulcers
Unusual bruising
Spontaneous bleeding – nose, mouth,
gums, rectum, vagina
Sores in the corner of mouth
Smooth tongue
Mild yellowing of eyes or skin
Susceptible to infections
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
N
N
N
N
N
N
Y (5)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
N
N
N
N
N
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
3
3
3
3
3
3
3
3
3
3
3
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
14.
3
3
3
3
3
3
3
3
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Total Points:
1.
2.
3.
4.
5.
6.
21.
Feel jittery
Heartburn that moves to neck, jaws,
left shoulder and arm
First effort of the day causes pain around
chest
Dizziness
Choking, smothering sensation
Exhaustion with minor exertion
0
1
2
3
0
1
2
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
1
1
2
2
3
3
0
1
2
3
0
1
2
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
0
1
2
3
0
1
2
3
0
1
2
3
0
N
N
N
1
2
3
Y (5)
Y (5)
Y (5)
Total Points:
20.
Section C
Heart pounds easily
Heavy sweating (no exertion)
Mild or severe chest pain
Difficulty catching breath esp. during
Exercise
Wheezing or dry cough
Heart palpitations: slow, rapid or irregular
Swelling in feet, ankle, legs which comes
and goes
Veins on neck are prominent
Section D
3.
Total Points:
Nosebleeds
Headache, typically in morning
Weakness, fatigue, nervous
Ringing in ears
Dizziness, drowsiness
Blushing – no apparent cause
Numbness, tingling in hands & feet
Blurred vision
11.
12.
13.
1.
2.
Section B
1.
2.
3.
4.
5.
6.
7.
8.
7.
8.
9.
10.
22.
23.
24.
25.
Fluid retention
Numbness, tingling, prickling sensation
in hands, feet
Muscle pain in calves or thighs when
Walking
Muscle pain at rest
Cold feet
Headaches
Dizziness, everything spins
Poor concentration
Slurred speech
Ringing in ears
Brief moments of hearing loss
Nausea comes and goes quickly
Falling without known cause
Brief difficulty swallowing
Brief difficulty speaking
Stammering or twitching of tongue
Double vision
Difficulty understanding spoken or
written word
Brief loss of muscular coordination in
legs, arms
Inability to recognize persons or things
that pass quickly
Inability to feel pain or temperature,
usually on one side, that disappears quickly
One leg or arm – shiny, hairless skin
Discolored or blue toes
Open sores on feet and legs
Fingers and toes numb in response to
cold weather even when protected
N
Y (5)
Total Points:
PART V
Section A
Section B
Missing meals or fasting is associated with the following:
1. Sudden anxiety associated with hunger
0
1
2. Tingling sensation in hands
0
1
3. Palpitations
0
1
4. Feel shaky, jittery, have tremors
0
1
5. Weakness
0
1
6. Profuse perspiration, clammy skin
0
1
7. Nightmares
0
1
8. Awake from sleep restless
0
1
9. Agitated, easily upset, nervous
0
1
10. Poor memory, forgetful
0
1
11. Confusion, disoriented
0
1
12. Dizziness, feel faint
0
1
13. Feeling cold, numbness
0
1
14. Mild headache
0
1
15. Blurred or double vision
0
1
16. Lack of coordination
0
1
Total Points:
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Excessive, frequent urination
Increased thirst and appetite
Blurred vision, failing eyesight
Fatigue, drowsiness
Crave sweets, but eating sweets
does not relieve craving
Feel hungry for air (can’t get enough)
Breath smells sweet
Depressed
Tingling, numbness, prickling
sensation in extremities
Profuse sweating
Dribble after voiding
Impotency
Dizziness when standing from
sitting position
Slurred speech
Unintentional weight loss
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
N
1
1
2
3
2
3
Y (3)
16. Recurring, persistent infection in bladder,
skin or gums
17. Boils and leg sores
N
N
18. Very slow wound healing
19. Excessive weight gain
Y (3)
Y (3)
N
N
Y (3)
Y (3)
Total Points:
PART VI
1.
2.
3.
4.
5.
6.
Weakness and fatigue
Chest discomfort, pain
Sudden breathing difficulty
Shortness of breath
Shallow breathing
Noisy rattling sounds when breathing
in or out
7. Cough – dry or moist
8. Rapid heartbeats
9. Excessive perspiration
10. Anxiety, restlessness
11. Consistent low grade fever (100-101)
12. Bluish nails and lips
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
0
0
1
1
2
2
3
3
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Sputum – thick, clear, yellow
Sputum – smells offensive
Bloody sputum
Bad breath
Wheezing
Loud snoring
Sleepy during the day
Morning headache
Difficulty concentrating
Unexplained weight loss
Infections settle in lungs
Flu symptoms last longer than 5 days
0
0
0
0
0
0
0
0
0
N
N
N
1
1
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (3)
Y (3)
Y (3)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
Total Points:
PART VII
1.
2.
3.
Retain fluid throughout body
Mild lower back pain
Frequent urge to urinate, but only small
amounts pass
4. Interruption of urine stream
5. Excessive urination
6. Excessive urination at night
7. Burning when urinating
8. Frequent urination with urgency
9. Rarely need to urinate
10. Difficulty passing urine
11.
12.
13.
14.
15.
16.
17.
18.
19.
Dripping after urination
Can’t hold urine
Bloody, cloudy and/or darkened urine
Strong smelling urine
Joint and muscle pain
Tingling in joints
Dark circles under eyes
Grey, blackish cast to skin
Back or leg pains associated with
dripping after urination
20. Poor skin elasticity
0
0
0
0
0
0
0
0
N
N
3
3
3
3
3
3
3
3
Y (5)
Y (3)
Total Points:
PART VIII (MEN ONLY)
Section A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Section B
Frequent or urgent need to urinate
Delayed, weak, or interrupted
urinary stream
Pain or burning upon urination
Urge to urinate several times a night
Rose colored (bloody) urine
Difficulty urinating
A sense of bladder fullness
Ejaculation causes pain
Blood in semen
Lack of sex drive
Impotency
Pain or fatigue in legs or back
Dripping after urination
Increased straining with small amounts of
urine passed
Anemia
0
1
2
3
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
0
N
1
2
3
Y (3)
Total Points:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Itchy patches around inner thigh & groin
0
Itching at night
0
Painful testicles
0
Difficulty attaining &/or maintaining
an erection
0
Low sexual drive
0
Premature ejaculation
0
Low energy level or stamina
0
Inflammation on the head of penis
N
Genital &/or rectal rash or irritation
N
Distorted nail growth
N
Loss of pubic hair or armpit hair
N
Infertile
N
Low sperm count, low sperm motility
N
Unexplained weight gain
N
Testicles appear smaller
N
Development of breasts or nipple tenderness N
Feeling of heaviness or hardness in testicle N
Sparse beard or slow hair growth
N
Decreased body hair
N
Fine wrinkling in corner of mouth or
around eyes
N
Total Points:
1
1
1
2
2
2
1
1
1
1
2
3
2
3
2
3
2
3
Y (5)
Y (5)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
Y (3)
3
3
3
PART IX (WOMEN ONLY)
Section A
Circle if you experience any of these symptoms within 3 days to
two weeks prior to menstruation (ovulation):
1. Insomnia
0
1
2
3
2. Abdominal bloating
0
1
2
3
3. Breast tenderness
0
1
2
3
4. Heart palpitations
0
1
2
3
5. Sweating and flushing
0
1
2
3
6. Depressed, irritable, nervous
0
1
2
3
7. Easy to anger, resentful
0
1
2
3
8. Easily overwhelmed
0
1
2
3
9. Nausea &/or vomiting
0
1
2
3
10. Diarrhea or constipation
0
1
2
3
11. Headache
0
1
2
3
12. Food cravings, binge eating
0
1
2
3
13. Back pain
0
1
2
3
14. Numbness, tingling in hands and feet
0
1
2
3
15. Clumsiness
0
1
2
3
16. Feeling hopeless, sad
0
1
2
3
17. Weight gain – water
N
Y (3)
18. Breast lumps appear
N
Y (3)
19. Suicidal
N
Y (10)
Total Points:
Section B
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Vaginal dryness, pain
Painful intercourse
Engorged breasts
Disinterest in sex
Blurred vision
Headache
Acne &/or oily skin
Aggressive feelings
Overwhelming urges for sexual intercourse
Absence of menstrual flow for six or
more months
Occasionally skip periods
Menstruation began after 16 yrs of age
Breasts shrinking
Thinning pubic and armpit hair
Unable to get pregnant
Miscarriage
Excess facial hair
Poor sense of smell
Monthly abdominal pain without bleeding
Milk production (not nursing)
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
N
N
N
N
N
N
N
N
N
N
N
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Y (20)
Y (5)
Y (3)
Y (5)
Y (5)
Y (10)
Y (3)
Y (5)
Y (3)
Y (5)
Y (10)
Total Points:
Section C
1.
2.
3.
4.
5.
6.
7.
8.
Painful intercourse
Menstrual type pain between menses
Irregular time intervals between periods
Extended menses (greater than every
32 days)
Shortened menses (less than every 24 days)
Vaginal bleeding between periods
Vaginal discharge between periods
Pain during periods is getting
progressively worse
0
N
N
1
2
3
Y (3)
Y (5)
N
N
N
N
Y (10)
Y (5)
Y (10)
Y (5)
N
Y (5)
Circle if you experience any of these symptoms during your
period:
9. Pain, cramps
0
1
10. Irritable and depressed
0
1
11. Constipation &/or diarrhea
0
1
12. Lower abdominal pain, bloating
0
1
13. Nausea &/or vomiting
0
1
14. Lower backache
0
1
15. Pelvic &/or rectal pressure
0
1
16. Urinary difficulties
0
1
17. Frequent urination
N
18. Unusual fatigue, can’t work
N
19. Scanty blood flow
N
20. Heavy blood flow
N
2
3
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (5)
Y (5)
Y (3)
Y (3)
Total Points:
Section D
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Clear, gray, or yellow vaginal discharge
0
Burning or itching of the external genitalia 0
Urgent, painful urination
0
Lower abdominal or back pain
0
Heavy, watery and bloody vaginal discharge 0
Pelvic cramps
0
Thin, scant, white vaginal discharge
0
Greenish, yellow, or offensive discharge
0
Cheesy white discharge
0
Breast lumps or swelling with or
without pain or tenderness
N
Lumps hurt just before period
N
Swelling under armpit
N
Change in breast size, shape
N
White or slightly bloody vaginal
discharge, one week prior to period
N
Heavy menstrual flow
N
Vaginal bleeding after sex or between
periods
N
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Y (10)
Y (5)
Y (5)
Y (5)
Y (10)
Y (3)
Y (5)
Total Points:
Section E
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Dry skin, hair, vagina
Disinterest in sex
Mood swings, irritable
Depression, anxiety, nervousness
Craving for sweets, binge eating
Headaches or dizziness
Painful intercourse
Sudden hot flashes
Spontaneous sweating
Shortness of breath &/or heart palpitations
Unpredictable vaginal bleeding
Difficulty holding urine
Difficulty sleeping
Mental fogginess
Vaginal pain &/or itching
Thin, scant white vaginal discharge
Low back &/or hip pain
Breast tenderness, pain or tingling,
prickling sensation
Thinning armpit and pubic hair
Stopped menstruating
Breasts beginning to shrink, sag
Abnormal growth of hair above lip
Easy bruising, loss of skin tone
Irregular menstrual cycle
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
N
N
N
N
N
N
1
Total Points:
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
Y (5)
Y (20)
Y (10)
Y (3)
Y (5)
Y (3)
PART X
6.
Section A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Generalized bone tenderness & achiness
Localized bone pain
Bone deformity with or without swelling
Shins hurt during or after exercise
Low back or hip pain
Difficulty sitting straight
Limp, walking difficulties
Crunching or creaking sounds when
move joints
Hands, feet, throat spasm or feel numb
Joint pain and stiffness – especially
spine, hips, knees
Hearing loss, headaches, ringing in ears
Cavities within the last two years
Tooth loss due to gum disease
Established bone loss
Calcium deposits around joints
Spinal curvature
(10)
Recent loss of height
Bow legs
Stooped posture
Hump at base of neck
Irregular patches of increased
Pigmentation
Unexplained bone fracture
0
0
0
0
0
0
0
1
1
1
1
1
1
1
0
0
1
1
0
0
N
N
N
N
N
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
2
3
2
3
Y (5)
Y (5)
Y (10)
Y (5)
Y
N
N
N
N
Y (10)
Y (5)
Y (5)
Y (5)
N
N
Y (3)
Y (10)
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
0
0
1
1
2
2
3
3
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
1
1
2
2
3
3
0
0
N
N
N
1
1
2
3
2
3
Y (3)
Y (3)
Y (3)
Total Points:
4.
5.
Joint stiffness, soreness, swelling
Red, swollen, painful joints
Joint stiffness, improves when resting,
worsens with movement
Dry mouth
Dry painful eyes
16.
17.
18.
19.
20.
23.
Section C
1.
2.
3.
12.
13.
14.
15.
22.
Section B
Muscle aches & pains
Muscle stiffness, tension
Specific points on body feel sore when
Pressed
Headaches
Fatigue, tired, sluggish
Difficulty sleeping
Feel unrefreshed upon awakening
Difficulty speaking/swallowing
Muscle cramps or spasm
Muscles twitch or tremble – eyelids,
thumb, calf muscle
Irresistible urge to move legs
Legs move during sleep
Unpleasant crawling sensation inside
calves, while lying down
Excessive joint mobility
Unable to fully straighten or extend
legs &/or arms
Upper or lower back pain
Loss of muscle strength
Muscle loss, wasting
Numbing, tingling sensation
10.
11.
21.
Total Points:
1.
2.
3.
7.
8.
9.
0
0
1
1
2
2
3
3
0
0
0
1
1
1
2
2
2
3
3
3
24.
25.
26.
27.
Joint stiffness worsens with rest, improves
with movement
0
Cracking joints
0
Limp
Shooting, aching, tingling pain down
the back of leg
0
Joint pain involves one or a few joints
0
Joints hurt when moving or when
carrying weight
0
Difficulty standing up from sitting position 0
Headache
0
Difficulty chewing food or opening mouth 0
Intermittent pain, ache on one side of head
spreading to cheek, temple, lower jaw,
ear, neck, and shoulder
0
Numbness, prickling, tingling sensation
in neck, shoulder, and arms
0
Injure, strain, sprain easily
0
Discomfort or pain in neck, shoulder, or arm 0
Involuntary muscle spasms
0
Deliberate movement with hands is
difficult
0
Red, painless skin lumps on elbows,
knees, toes, ear, nose, back of scalp
N
Knobby overgrowths on joints closest
to the fingertips
N
Muscle loss around inflamed joint
N
(10)
Double jointed
N
One leg shorter than the other
N
Walk slowly
N
Limited range of motion
N
1
1
2
2
3
3
1
1
2
2
3
3
1
1
1
1
2
2
2
2
3
3
3
3
1
2
3
1
1
1
1
2
2
2
2
3
3
3
3
1
2
3
Y (5)
Y (5)
Y
Y (3)
Y (5)
Y (3)
Y (3)
Total Points:
Section D
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Head feels heavy
Light headedness/fainting
Ringing/buzzing in ears
Trembling hands
Limbs feel too heavy to hold up
Loss of feeling in hands &/or feet (toes)
Tingling sensation followed by numbness,
or pain begins in hands and feet and
spreads toward the center of your body
Unsteady gait, lose balance
Muscles feel weak
Weak grip with spasm and arm weakness
Exhaustion on slightest effort
Need for 10-12 hours sleep
Muscular weakness begins in leg and
moves upward
Difficulty walking, moving around,
handling small objects
Nervous, anxious
Confused, forgetful
Slowed or slurred speech
Difficulty breathing
Blurred vision
Eyelids droop
Accident prone – trip, stumble, feel clumsy
Impaired hearing, eyesight, sense of touch,
smell, taste
Convulsion
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
1
2
3
0
0
0
0
0
0
0
N
1
1
1
1
1
1
1
2
3
2
3
2
3
2
3
2
3
2
3
2
3
Y (5)
N
N
Total Points:
Y (15)
Y (15)

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