Health Appraisal – Male Health Appraisal QuestionnaireFirst Name *Surname *Date of Birth *Email *Symptom Severity / Frequency 0 = Never 1 = Mild or Infrequent Symptoms (twice per week or less) 2 = Moderate or Frequent Symptoms (3-6 times a week) 3 = Severe or Daily SymptomsTip If your response is Never (0) you do not need to click this in and you can leave that question blank. If however you do change your mind for example from Mild (1) to Never (0) you will need to click.Section 11. Curved spine, height loss, stooped base of neck hump (dowager’s hump) 01232. Bone pain, back, hip or knee pain 01233. Spinal problems, pain, Sciatic pain 01234. Osteoporosis 01235. Recent broken bones, fractures 01236. Arthritis - Osteo/Rheumatoid 01237. Joints swelling painful, deformity, injury, stiffness 01238. Noisy joints (creak, grind etc.) 01239. Nodules on fingers 012310. High uric acid level / Gout 012311. Damaged disc, slipped disc 012312. Bursitis or tendonitis 0123Section 21. Tightness or pain in back, neck or shoulder muscles 01232. Muscular spasms, cramping 01233. Stiffness in muscles 01234. Tenderness, pain in muscles 01235. Weakness in muscles 01236. Trembling (fasciculation) 0123Section 31. Chest tightness on stress or exertion 01232. Palpitations, arrythmias, extra beats 01233. Swelling of the ankles 01234. Shortness of breath on exertion/rest 01235. Calf pain on exercise 01236. Dizziness on exertion 01237. Previous angina attacks, heart attack or stroke YesNo8. Known cardiac murmur or condition YesNo10. High blood cholesterol, triglycerides or blood clotting problems YesNo10. Blood Pressure or Heart medication YesNoSection 41. Blue, numb, cold fingers or toes YesNo2. Ulcers, sores on legs and feet YesNo3. Shiny, discoloured, hairless skin on arms or legs / Varicose veins YesNo4. Cramps, pain in legs when walking 01235. Pins and needles, numbness - hands, feet 01236. Fluid retention feet, legs, body 01237. Difficulty with written or spoken words or concentration 01238. Dizzyness, ringing in the ears 01239. Fleeting nausea / Hearing loss 012310. Previous deep vein thrombosis 012311. Take Anti-clotting medication YesnoSection 51. Morning headaches 01232. Feel tired, nervy, weak 01233. Ringing in ears / Sleepy, dizzy 01234. Flushing with no known cause 01235. Tingling and numb hands and feet 01236. Blurry vision 0123Hi Blood Pressure / Heart medication YesNoSection 61. Smoker Yesno2. Cough 01233. Asthma, Wheezing 01234. Repeated chest infections / Gets chest infections easily 01235. Shortness of breath on effort or at rest 12306. Chest pain on breathing or coughing 01237. Coughing up mucus/phlegm 01238. Takes asthma medication YesNoSection 71. Burping up gas 01232. Bloating after meals 01233. Abdominal distention, swelling 01234. Less than 1 bowel movement per day 01235. Food intolerances, allergies 01236. Foul smelling breath 01237. Low vitamin B12 levels YesNo8. Acne or Acne Rosacea 01239. Eczema 012310. Flaking, peeling or brittle nails 0123Section 81. Past duodenal ulcers, stomach problems YesNo2. Do you have an ulcer now ? YesNo3. Do you use antacids ? YesNo4. Stomach pains on lying down or bending after a meal 01235. Stomach symptoms, heartburn, pain 01236. Food, drink makes stomach feel better 01237. Black stools (blood) 01238. Helicobacter breath test positive YesNoSection 91. Abdominal cramps after eating meals 01232. Abdominal cramps opening bowels 01233. Loose stools, constipation 01234. Tiredness after meals 01235. Smelly stools 01236. Acne, Food allergies 01237. Inflammation of the small bowel 01238. Mucous in stools 01239. Fullness, indigestion for 2-4 hrs after meals 012310. Bowel gas, flatulence, wind 0123Section 101. Chronic fungal infections, thrush, parasites abnormal bacteria 01232. Low fibre diet 0123Constipation, diarrhea, colitis 01234. Antibiotic use (note frequency) 01235. High meat intake 01236. Abdominal pain, Diverticulitis 01237. Bowel gas, flatulence, wind 01238. Abdominal pain, Diverticulitis / Diverticulosis 01239. Changeable bowel habits 012310. Red blood in stool (or blood found in stool on testing) 0123Section 111. Indigestion, pain or nausea after eating or nausea after drinking alcohol 01232. Previous hepatitis or abnormal liver function tests YesNo3. Pain under front right side of rib cage, right side of back 01234. Yellowness of sclera (whites of eyes) 01235. Indigestion or pains after fatty food 01236. Light coloured stools, dark urine 01237. High cholesterol or triglycerides 01238. Strong smelling urine after eating asparagus YesNo9.Gallstones, pain under right hand side of rib cage 012310. Irritability, depression, foggy thinking 012311. Reddened palms or skin 012312. Fatigue, tired all the time, generally feels unwell 0123Section 121. Poor sense of smell and taste 01232. Dark under the eyes, on cheeks 01233. Cold sores, herpes, HPV, HIV YesNo4. Catch colds and flu easily YesNo5. Nasal blockage, mucus, post nasal drip, sore throat 01236. Frequent antibiotic use 01237. Ear, nose, throat, eyes, lung, skin infections 01238. Discharge from ears 01239. Swelling in groin, armpits, neck 0123Section 131. Hayfever, sinusitis 01232. Headaches & Migraine 01233. Eczema, psoriasis, dermatitis YesNo4. Urticaria (hives) YesNo5. Arthritis (osteo, rheumatoid) 01236. Itching or red eyes 01237. Mouth ulcers 01238. Sensitive to chemicals YesNo9. Hyperactive, ADD, ADHD, Learning difficulties YesNo10. Asthma, wheezing YesNo11. Chronic cough/hoarseness 012312. MS, SLE, other autoimmune diseases YesNoSection 141. Fatigue, tired all the time 01232. Poor tolerance to stress 01233. Salt cravings 01234. Poor exercise tolerance 01235. Food sensitivities 01236. Environmental pollutant sensitivity 01237. Feels dizzy, blurry vision when rising or standing up 01238. Irritability, rapid mood swings 01239. Slow recovery from infections 012310. Changes in skin pigmentation, colour 0123Section 151. Sensitive to cold 01232. Depression 01233. Fatigue 01234. Constipation 01235. Dry skin 01236. Fluid retention 01237. Loss of hair anywhere on the body 01238. Difficulty in losing weight 0123Section 161. Sweating if food is delayed, irritability if meals are missed 01232. Frequent copious urination and increased thirst 01233. Tremors or shakiness if meals missed 01234. Dizziness after sugary food or drink 01235. Craving coffee or stimulants 01236. Headaches if meals are missed 01237. Poor memory 01238. Eating relieves symptoms 01239. Difficulty in losing weight or slow recovery from infections 012310. Immediate family member has a history of diabetes YesNoSection 171. Bed wetting 01232. Frequent urination 01233. Frequent infections 01234. Blood or protein in urine 01235. Puffy eyelids 01236. Antibiotics for urinary infections 01237. Polyps in urethra or bladder 01238. Strong smelling urine 01239. Dripping after or poor urine stream 012310. Incontinence on exertion, sneezing etc. 0123Section 23 (sections 18 - 22 are female sections)1. Low libido 01232. Premature ejaculation 01233. Difficulty developing or maintaining an erection 01234. Burning on urination 01235. Aching at back of legs, rectal area 01236. Difficulty in urinating, dripping after urination 01237. Low sperm number and / or motility YesNo8. Previous sexually transmitted disease YesNo9. Varicocele YesNo10. Blood or other discharge from penis YesNo11. Genital warts / lesions YesNoSection 241. Light headedness/vertigo 01232. Walking difficulties 01233. Poor bowel / bladder control 01234. Speech difficulties 01235. Weakness of limbs 01236.Muscle twitching 01237. Sensory, perception changes - temperature, numbness, tingling 01238. Short / long-term memory loss 01239. Poor co-ordination / balance 012310. Paralysis, spasticity YesNoSection 251. Cerebravascular - Stroke, transient ischaemic attacks, haemorrhage YesNo2. Alzheimer’s disease senile dementia YesNo3. Tremor 01234. Parkinson’s disease YesNo5. Motor neurone disease YesNo6. Epilepsy YesNoSection 261. Chronic pain at any site 01232. Headaches, migraines, cluster headaches 01233. Neuralgia - Trigeminal following herpes/shingles infection 01234. Addiction to recreational drugs YesNo5. Difficulty giving up smoking YesNo6. Need to have at least one alcoholic drink each day YesNo7. Reflex sympathetic dystrophy YesNo8. Chronic arthritis 01239. Food addiction/ anorexia/ bulimia YesNo10. Depends on medication for pain YesNoSection 271. Forgetful 01232. Difficult concentration 01233. Treated for schizophrenia YesNo4. Depression YesNo5. Obsessive compulsive disorder YesNo6. Easily distracted, learning problems 01237. Suicidal thoughts YesNo8. Anxiety, Waking with anxiety YesNo9. Panic Attacks YesNo10. Mood swings 0123Section 281. Vivid dreams 01232. Light sleep 01233. Sleep talking 01234. Sleep walking 01235. Snoring (sleep apnoea) 01236. Difficulty falling asleep 01237. Early morning waking 01238. Frequent waking 01239. Wake during night with difficulty getting back to sleep YesNo10. Waking up exhausted 0123 This box is for spam protection - <strong>please leave it blank</strong>:
