Health Appraisal Questionnaire

This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.

0 = No or Rarely — You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or less)

1 = Occasionally — Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger

4 = Often — Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it

8 = Frequently — Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis

Patient Name (Required)

Section A

	0	1	4	8
Indigestion, food repeats on you after you eat
Excessive burping, belching and/or bloating following meals
Stomach spasms and cramping during or after eating
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
Bad taste in your mouth
Small amounts of food fill you up immediately
Skip meals or eat erratically because you have no appetite

Section B

	0	1	4	8
Strong emotions, or the thought or smell of food aggravates your stomach or makes it hurt
Feel hungry an hour or two after eating a good-sized meal
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
Burning sensation in the lower part of your chest, especially when lying down or bending forward
Digestive problems that subside with rest and relaxation
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
Feel a sense of nausea when you eat
Difficulty or pain when swallowing food or beverage

Section C

	0	1	4	8
When massaging under your rib cage on your left side, there is pain, tenderness or soreness
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
Specific foods/beverages aggravate indigestion
The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
Stool odor is embarrassing
Undigested food in your stool
Three or more large bowel movements daily
Diarrhea (frequent loose, watery stool)
Bowel movement shortly after eating (within 1 hour)