Health Appraisal Questionnaire 12 (Women Only)

Name*
Date*
MM slash DD slash YYYY
Email*
Phone*
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?
[A]
Anxious, irritable or restless*
Numbness, tingling in hands and feet*
Easy to anger, resentful*
Aggressive or hostile toward family/friends*
[B]
Abdominal bloating, feeling swollen (e.g., feet)*
Temporary weight gain*
Breast tenderness, swelling*
Appearance of breast lumps*
Discharge from nipples*
Nausea and/or vomiting*
Diarrhea or constipation*
Aches and pains (back, joints, etc.)*
[C]
Craving for sweets*
Increased appetite or binge eating*
Headaches*
Being easily overwhelmed, shaky or clumsy*
Heart pounding*
Dizziness or fainting*
[D]
Confused and forgetful to the point that work suffers*
Overwhelmed with feelings of sadness and worthlessness*
Difficulty sleeping or falling asleep*
Engaging in self-destructive behavior*
Total points*
Section B
Do you experience any of these symptoms during your period?
Cramping in lower abdomen or pelvic area*
Lower abdominal pain is sharp and/or dull or intermittent*
Bloating and sense of abdominal fullness*
Diarrhea and constipation*
Nausea and/or vomiting*
Low back and/or legs ache*
Headaches*
Unusual fatigue (take naps) resulting in missed work*
Painful and/or swollen breasts*
Scanty blood flow*
Total points*
Section C
Painful or difficult sexual intercourse*
Lower abdominal, back and vaginal pain throughout the month*
Pelvic pressure or pain while sitting down or standing up, relieved by lying down*
Vaginal bleeding other than during your period*
Painful bowel movements*
Difficult (straining) urination*
Abnormal vaginal discharge*
Offensive vaginal discharge*
Vaginal itching or burning with or without intercourse*
Pain during periods is getting progressively worse*
Profuse or prolonged menstrual bleeding*
Unable to get pregnant*
Total points*
Section D
Absence of periods for six months or longer*
Periods occur irregularly (e.g. 3 to 6 times a year)*
Profuse heavy bleeding during periods*
Menstrual blood contains clots and tissue*
Bleeding between periods can occur anytime*
Periods occur greater than every 35 days*
Intense upper stomach pain, lasting several hours at the first time you ovulate (approx. day 14 of your cycle)*
Bleeding occurs at ovulation (approx. day 14 of your cycle)*
Monthly abdominal pain without bleeding*
Abundant cervical mucus*
Overwhelming urges for sexual intercourse*
Aggressive feelings*
Increased growth of dark facial and/or body hair*
Poor sense of smell*
Voice is becoming deeper*
Breasts seem to be getting smaller*
Receding hairline*
Total points*
Section E
Vaginal discharge*
Vaginal secretions are watery and thin*
Vaginal dryness*
Sexual intercourse is uncomfortable*
Interest in having sex is low*
Engorged breasts*
Breast tenderness, soreness*
Difficulty with orgasm*
Vaginal bleeding after intercourse*
Do you skip periods?*
The length (# of days) of your period varies month to month, with the # of days of bleeding getting fewer*
Total points*
Section F
Sense of well-being fluctuates throughout the day for no apparent reason*
Sudden hot flashes*
Spontaneous sweating*
Chills*
Cold hands and feet*
Heart beats rapidly or feels like it is fluttering*
Numbness, tingling or prickling sensations*
Dizziness*
Mental fogginess, forgetful or distracted*
Inability to concentrate*
Depression, anxiety, nervousness and/or irritability*
Difficulty sleeping*
Conscious of new feelings of anger and frustration*
Skin, hair, vagina and/or eyes feel dry*
Stopped menstruating around six months ago, yet still experience some vaginal bleeding*
Total points*
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.).
Front of body*
- Af
- Bf
- Cf
- Df
- Ef
- Ff
- Gf
- Hf
- If
- IIf
- Jf
- JJf
- Kf
- KKf
- Lf
- LLf
- Mf
- Nf
- Of
- Pf
- Qf
- Rf
- Sf
- Tf
- Uf
- Vf
- Wf
- Xf
- Yf
- Zf
- 1f
- 2f
Back of body*
- Ab
- Bb
- Cb
- Db
- Eb
- Fb
- Gb
- Hb
- Ib
- IIb
- Jb
- JJb
- Kb
- KKb
- Lb
- LLb
- Mb
- Nb
- Ob
- Pb
- Qb
- Rb
- Sb
- Tb
- Ub
- Vb
- Wb
- Xb
- Yb
- Zb
- 1b
- 2b
Describe what you feel or observe in your own words. Write in the box below:*
Let us know you are human