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Health Appraisal Questionnaire 12 (Women Only)

  • Date Format: MM slash DD slash YYYY
  • Part XII Women Only

    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 programs, 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.

    For each question, select the number that best describes your symptoms: 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.

    Some questions require a Yes or No response.

    (Menopausal women should skip to Section E and F)

    Section A

    Do you persistently experience any of these symptoms within three days to two weeks prior to menstruation?

  • [B]
  • [C]
  • [D]
  • Section B

    Do you experience any of these symptoms during your period?

  • Section C
  • Section D
  • Section E
  • Section F
  • Using the checkboxes below, indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or texture (e.g., moles, rashes, etc.).

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