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Health Assessment Questionnaire v.11
______________________
Health Assessment Questionnaire is an inventory of symptoms specific to the patient's health problems. The information derived from this questionnaire is equivalent to a four-hour interview. The cost of the questionnaire is US$80.00*, payable at the completion of the questionnaire. The answers are processed by a proprietary algorithm that generates a numerical representation of the state of health, allowing for precise tracking of changes through the health improvement program.
After completing the questionnaire, click "SUBMIT." We will contact you soon.
Thank you for entrusting your health needs to us.
World-Wide Naturopathic Health Service
*If you do not want to continue, click your browser's back button.
IMPORTANT NOTICE: There is a short telephone/Internet consultation included in the fee for Health Assessment Questionnaire. However, there is a separate fee for a full consultation (up to an hour, office or Internet) – should it be required, subject to the patient’s approval. There is no obligation of any kind whatsoever to request such consultation or to buy any naturopathic formulations, remedies, or supplements from our dispensary. For more information, go to http://www.kulisz.com/practice/office-fees/
_______________________
Ver. 11.0
First and last name
*
First
Last
New or established patient?
*
Please select
New
Established
If the last appointment was 6 months ago or more, select NEW
Today's date
*
MM
/
DD
/
YYYY
Age
*
Full years
Gender
*
Please select
Male
Female
Height
*
In inches or centimeters
in/cm
*
Please select
Inches
Centimeters
Select inches or centimeters
Weight
*
Round up to full number
lbs/kilos
*
Please select
Pounds
Kilos
Select pounds or kilos
Blood pressure
*
Example: 130/80. Enter 999/99 if unknown.
Cholesterol (Enter 999 in all fields if unknown)
*
Total
LDL
HDL
Cholesterol
How are you?
Please select
Much better
Better
Slightly better
No change
Slightly worse
Worse
Much worse
Please tell us how is your overall health comparing to previous assessment.
Phone
*
No hyphens, no spaces. Non US and Canadian filers, please include country code.
Email
*
Confirm
Referred by
*
Please select
Dr. Kulisz
Office Staff
Self referred
Website
Youtube
Radio, TV
Family or friend
Other
Other
Primary health concerns
*
If none, write 'None"
Allergies
*
If none, write "None"
Medications you are currently taking
*
If none, write "None"
Are you pregnant?
*
Yes
No
Do you use tobacco?
*
Yes
No
Are you at risk for falls or falling injuries?
*
Yes
No
In the following survey please rate symptoms that apply to you. If symptom does not apply to you, leave it marked "0" or "-"(default).
Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.
Symptoms Group 1
1
2
3
4
0
1.1 Acid foods upset
1
2
3
4
-
1.2 Chills
1
2
3
4
-
1.3 “Lump” in throat
1
2
3
4
-
1.4 Dry mouth, eyes, nose
1
2
3
4
-
1.5 Pulse speeds after meal
1
2
3
4
-
1.6 Easily irritable, difficult to calm
1
2
3
4
-
1.7 Cuts heal slowly
1
2
3
4
-
1.8 Gag easily
1
2
3
4
-
1.9 Unable to relax/startles easily
1
2
3
4
-
1.10 Extremities cold, clammy
1
2
3
4
-
1.11 Strong light irritates
1
2
3
4
-
1.12 Urine amount reduced
1
2
3
4
-
1.13 Heart pounds after retiring
1
2
3
4
-
1.14 “Nervous” stomach
1
2
3
4
-
1.15 Appetite reduced
1
2
3
4
-
1.16 Cold sweats
1
2
3
4
-
1.17 Develops fever easily
1
2
3
4
-
1.18 Neuralgic pains
1
2
3
4
-
1.19 Staring, blinks little
1
2
3
4
-
1.20 Frequent sour stomach
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 2
1
2
3
4
0
2.1 Stiff joints after wakeup
1
2
3
4
-
2.2 Leg cramps at night
1
2
3
4
-
2.3 “Butterfly” stomach, cramps
1
2
3
4
-
2.4 Watery eyes and/or nose
1
2
3
4
-
2.5 Eyes blink often
1
2
3
4
-
2.6 Swollen, puffy eyelids
1
2
3
4
-
2.7 Indigestion soon after meals
1
2
3
4
-
2.8 Always seem hungry; feels “lightheaded”
1
2
3
4
-
2.9 Rapid digestion
1
2
3
4
-
2.10 Frequent vomiting
1
2
3
4
-
2.11 Frequent hoarseness
1
2
3
4
-
2.12 Irregular breathing
1
2
3
4
-
2.13 Pulse slow; feels “irregular”
1
2
3
4
-
2.14 Gagging reflex
1
2
3
4
-
2.15 Difficulty swallowing
1
2
3
4
-
2.16 Alternating constipation, diarrhea
1
2
3
4
-
2.17 "Slow starter"
1
2
3
4
-
2.18 Chills
1
2
3
4
-
2.19 Easily perspire
1
2
3
4
-
2.20 Poor circulation
1
2
3
4
-
2.21 Subject to colds
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 3
1
2
3
4
0
3.1 Eat when nervous
1
2
3
4
-
3.2 Excessive appetite
1
2
3
4
-
3.3 Hungry between meals
1
2
3
4
-
3.4 Irritable when hungry
1
2
3
4
-
3.5 Trembling, “shaky” when hungry
1
2
3
4
-
3.6 Fatigued when hungry
1
2
3
4
-
3.7 Dizzy, lightheaded when hungry
1
2
3
4
-
3.8 Heart palpitations when hungry
1
2
3
4
-
3.9 Blurred vision, difficulty focusing eyesight when hungry
1
2
3
4
-
3.10 Afternoon headaches
1
2
3
4
-
3.11 "Sugar rush" from overeating sweets
1
2
3
4
-
3.12 Awaken after few hours' sleep - hard to get back to sleep
1
2
3
4
-
3.13 Crave sweets or coffee
1
2
3
4
-
3.14 Depressed moods
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 4
1
2
3
4
0
4.1 Hands and feet get numb easily
1
2
3
4
-
4.2 Sigh frequently, “air hunger”
1
2
3
4
-
4.3 Aware of “breathing heavily”
1
2
3
4
-
4.4 High altitude discomfort
1
2
3
4
-
4.5 Opens windows in closed room
1
2
3
4
-
4.6 Susceptible to colds and fevers
1
2
3
4
-
4.7 Afternoon “yawner”
1
2
3
4
-
4.8 Drowsiness, lightheadedness
1
2
3
4
-
4.9 Swollen ankles, worse at night
1
2
3
4
-
4.10 Muscle cramps, worse during exercise
1
2
3
4
-
4.11 Shortness of breath on exertion
1
2
3
4
-
4.12 Dull pain in chest or radiating into left arm, worse on exertion
1
2
3
4
-
4.13 Bruise easily, “black and blue” spots
1
2
3
4
-
4.14 Tendency to anemia
1
2
3
4
-
4.15 Frequent nose bleeds
1
2
3
4
-
4.16 Noises in head, or ringing in ears
1
2
3
4
-
4.17 Tension under breastbone, or feeling of “tightness”, worse on exertion
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 5
1
2
3
4
0
5.1 Dizziness
1
2
3
4
-
5.2 Dry skin
1
2
3
4
-
5.3 Burning feet
1
2
3
4
-
5.4 Blurred vision
1
2
3
4
-
5.5 Itching skin and feet
1
2
3
4
-
5.6 Excessive falling hair, alopecia
1
2
3
4
-
5.7 Frequent skin rashes
1
2
3
4
-
5.8 Bitter, metallic taste in mouth in mornings
1
2
3
4
-
5.9 Bowel movements painful or difficult
1
2
3
4
-
5.10 Worrier, feels insecure
1
2
3
4
-
5.11 Feeling queasy; headache over eyes
1
2
3
4
-
5.12 Greasy foods upset
1
2
3
4
-
5.13 Stools light-colored
1
2
3
4
-
5.14 Skin peels on foot soles
1
2
3
4
-
5.15 Pain between shoulder blades
1
2
3
4
-
5.16 Use laxatives
1
2
3
4
-
5.17 Stools soft or watery
1
2
3
4
-
5.18 History of gallbladder attacks or gallstones
1
2
3
4
-
5.19 Sneezing attacks
1
2
3
4
-
5.20 Nightmares, bad dreams
1
2
3
4
-
5.21 Bad breath (halitosis)
1
2
3
4
-
5.22 Lactose intolerance
1
2
3
4
-
5.23 Sensitive to hot weather
1
2
3
4
-
5.24 Burning or itching anus
1
2
3
4
-
5.25 Crave sweets
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 6
1
2
3
4
0
6.1 Lost taste for meat
1
2
3
4
-
6.2 Coated tongue
1
2
3
4
-
6.3 Indigestion after meal
1
2
3
4
-
6.4 Burning stomach, food relieves
1
2
3
4
-
6.5 Gas shortly after eating
1
2
3
4
-
6.6 Passing gas several hours after eating
1
2
3
4
-
6.7 Stomach “bloating” after meal
1
2
3
4
-
6.8 Passing large amounts of foul-smelling gas frequently
1
2
3
4
-
6.9 Mucous colitis or “irritable bowel” syndrome
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 7
1
2
3
4
0
7.1 Insomnia
1
2
3
4
-
7.2 Nervousness
1
2
3
4
-
7.3 Can’t gain weight
1
2
3
4
-
7.4 Intolerance to heat
1
2
3
4
-
7.5 Emotional personality
1
2
3
4
-
7.6 Flush easily
1
2
3
4
-
7.7 Night sweats
1
2
3
4
-
7.8 Thin, moist skin
1
2
3
4
-
7.9 Inward trembling
1
2
3
4
-
7.10 Heart palpitations
1
2
3
4
-
7.11 Increased appetite without weight gain
1
2
3
4
-
7.12 Pulse fast at rest
1
2
3
4
-
7.13 Eyelids and/or face twitching
1
2
3
4
-
7.14 Irritable and restless
1
2
3
4
-
7.15 Can’t work under pressure
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 8
1
2
3
4
0
8.1 Weight gain
1
2
3
4
-
8.2 Appetite decrease
1
2
3
4
-
8.3 Fatigue easily
1
2
3
4
-
8.4 Ringing in ears
1
2
3
4
-
8.5 Sleepy during day/low energy
1
2
3
4
-
8.6 Sensitive to cold
1
2
3
4
-
8.7 Dry or scaly skin
1
2
3
4
-
8.8 Constipation
1
2
3
4
-
8.9 Mental "fog"/sluggishness
1
2
3
4
-
8.10 Hair coarse, falls out
1
2
3
4
-
8.11 Headaches upon arising, wear off during day
1
2
3
4
-
8.12 Slow pulse, below 65
1
2
3
4
-
8.13 Frequent urination
1
2
3
4
-
8.14 Impaired hearing
1
2
3
4
-
8.15 Reduced initiative
1
2
3
4
-
Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.
If the symptom does not apply to you, leave it marked "0" (default).
Symptoms Group 9
1
2
3
4
0
9.1 Failing memory
1
2
3
4
-
9.2 Low blood pressure
1
2
3
4
-
9.3 Increased sex drive
1
2
3
4
-
9.4 Headaches splitting/rendering type
1
2
3
4
-
9.5 Decreased sugar tolerance
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 10
1
2
3
4
0
10.1 Abnormal thirst
1
2
3
4
-
10.2 Bloated abdomen
1
2
3
4
-
10.3 Weight gain around hips or waist
1
2
3
4
-
10.4 Sex drive reduced or lacking
1
2
3
4
-
10.5 Tendency to ulcers, colitis
1
2
3
4
-
10.6 Increased sugar tolerance
1
2
3
4
-
Symptoms Group 10A Women
1
2
3
4
0
10.7 Adults: Menstrual disorders
1
2
3
4
-
10.8 Teens: Lack of menstruation
1
2
3
4
-
Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.
If the symptom does not apply to you, leave it marked "0" (default).
Symptoms Group 11
1
2
3
4
0
11.1 Dizziness
1
2
3
4
-
11.2 Headaches
1
2
3
4
-
11.3 Hot flashes
1
2
3
4
-
11.4 Increased blood pressure
1
2
3
4
-
11.5 Sugar in urine (not diabetes)
1
2
3
4
-
Symptoms Group 11A Women
1
2
3
4
0
11.6 Hair growth on face or body (female)
1
2
3
4
-
11.7 Masculine tendencies (female)
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 12
1
2
3
4
0
12.1 Weakness, dizziness
1
2
3
4
-
12.2 Chronic fatigue
1
2
3
4
-
12.3 Low blood pressure
1
2
3
4
-
12.4 Nails, weak, ridged
1
2
3
4
-
12.5 Tendency to hives
1
2
3
4
-
12.6 Arthritic tendencies
1
2
3
4
-
12.7 Perspiration increase
1
2
3
4
-
12.8 Bowel disorders
1
2
3
4
-
12.9 Poor circulation
1
2
3
4
-
12.10 Swollen ankles
1
2
3
4
-
12.11 Crave salt
1
2
3
4
-
12.12 Brown spots or bronzing of skin
1
2
3
4
-
12.13 Allergies - tendency to asthma
1
2
3
4
-
12.14 Weakness after colds, influenza
1
2
3
4
-
12.15 Physical/mental exhaustion
1
2
3
4
-
12.16 Respiratory disorders
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 13
1
2
3
4
0
13.1 Acoustic hallucinations
1
2
3
4
-
13.2 Anorexia
1
2
3
4
-
13.3 Anxiety
1
2
3
4
-
13.4 Apprehension
1
2
3
4
-
13.5 Confusion
1
2
3
4
-
13.6 Craving for sweets
1
2
3
4
-
13.7 Depression
1
2
3
4
-
13.8 Distraction
1
2
3
4
-
13.9 Dizziness
1
2
3
4
-
13.10 Fatigue
1
2
3
4
-
13.11 Feeling something dreadful will happen
1
2
3
4
-
13.12 Forgetfulness
1
2
3
4
-
13.13 Headache
1
2
3
4
-
13.14 Hypochondria
1
2
3
4
-
13.15 Indigestion
1
2
3
4
-
13.16 Insomnia
1
2
3
4
-
13.17 Instability
1
2
3
4
-
13.18 Irritability
1
2
3
4
-
13.19 Morbid fears
1
2
3
4
-
13.20 Muscular soreness
1
2
3
4
-
13.21 Nervousness
1
2
3
4
-
13.22 Neuralgia (sharp pain that follows path of a nerve)
1
2
3
4
-
13.23 Neuritis (inflammation of a nerve, pain, and/or loss of reflexes)
1
2
3
4
-
13.24 Noise sensitivity
1
2
3
4
-
13.25 Poor appetite
1
2
3
4
-
13.26 Tendency to cry without reason
1
2
3
4
-
13.27 Weakness
1
2
3
4
-
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
Symptoms Group 14F -- Women only
1
2
3
4
0
14F.1 Very easily fatigued
1
2
3
4
-
14F.2 Premenstrual tension
1
2
3
4
-
14F.3 Painful menses
1
2
3
4
-
14F.4 Depressed before menstruation
1
2
3
4
-
14F.5 Prolonged, excessive menses
1
2
3
4
-
14F.6 Painful breasts
1
2
3
4
-
14F.7 Menses too frequent
1
2
3
4
-
14F.8 Vaginal discharge
1
2
3
4
-
14F.9 Hysterectomy/ovaries removed
1
2
3
4
-
14F.10 Menopausal hot flashes
1
2
3
4
-
14F.11 Menses missed or scant
1
2
3
4
-
14F.12 Acne, worse at menses
1
2
3
4
-
14F.13 Depression of long standing
1
2
3
4
-
Symptoms Group 14M -- Men only
1
2
3
4
0
14M.1 Prostate problems
1
2
3
4
-
14M.2 Urination difficult or dribbling
1
2
3
4
-
14M.3 Night urination frequent
1
2
3
4
-
14M.4 Depression
1
2
3
4
-
14M.5 Pain on inside of legs or heels
1
2
3
4
-
14M.6 Feeling of incomplete bowel evacuation
1
2
3
4
-
14M.7 Lack of energy
1
2
3
4
-
14M.8 Migrating aches and pains
1
2
3
4
-
14M.9 Tire too easily
1
2
3
4
-
14M.10 Avoids activity
1
2
3
4
-
14M.11 Leg nervousness at night
1
2
3
4
-
14M.12 Diminished sex drive
1
2
3
4
-
15. Additional information:
*
Write here questions you want ask and provide additional information that you feel is pertinent to your health. If none, type "None"
Version 10.0
