Women Health Program Questionnaire


[FrontPage Save Results Component]

Your Personal Health Evaluation

Name:______________________________________________

Birth Date:_____________________________

 Address:_____________________________________________

Home Phone:____________________________

City, State, Zip: _______________________________________

Alternate Phone:____________________________

E-mail Address: __________________________________________

Please read every item carefully and put a check mark in the box next to each item that applies to you. If you do not understand the question, put a question mark (?) in the box. Attach a separate sheet to indicate your main health complaints.  

Please fax completed form to (817) 292-3335.  If you need any help, please call (817) 469-8823.

Rating Table
0 no symptoms
1 intermittent, does not affect quality of life
2 episodic, and interferes with quality of life
3 constant/chronic, and interferes with quality of life
4 constant/chronic, and severely interferes with quality of life
Check if applies Enter

Rating

0,1,2,3 or 4

 

 

 1 I am pregnant
 2a I am chemically sensitive
 2b I am environmentally sensitive
 3 I have cancer or Hepatitis B,C,D... Indicate _________________
 4a Most of my physical problems disturb me during the day        
 4b Most of my physical problems disturb me during the night
 5 Sensitive to cold such as cold weather, ice water and cold food
 6 Sensitive to heat such as hot weather and rooms without air conditioner
 7 Sweat profusely after doing light physical work such as vacuuming or mopping
 8 Sweat profusely during the night
 9 I have, or had shingles (herpes zoster)
10 Dizziness
11 Pain in the body.  Indicate region of pain ______________ How long? _________
12 Constipation
13 Diarrhea
14 Kidney failure.  I am receiving kidney dialysis. How many times per week? __________
15 Sexual potency problems or lack of sexual desire
16 Heavy alcohol consumption
17a Addictions to nicotine              How long? __________
17b Addictions to caffeine              How long?__________
17c Addictions to cocaine              How long?__________
17d Addictions to social drugs        How long?__________
18 Frequent use of antibiotics        How long?__________
19 HIV positive
20a Dry skin   
20b Itching
20c Skin peeling
20d Acne
20e Age spots
21a Breast implants  Date: __________         
21b Chemo/radiation therapy  Date:__________
22 Skin disease, skin burn or cut.  Name of skin disease __________
23a Ear ringing    
23b Hearing loss
24 Poor sleep or I wake up at least two times during the night
25 Snore while sleeping
26a Irregular menstrual flow              
26b Excessive menstrual flow
26c Early menopause
26d Cramps before menstrual flow
27 Vulva / vaginal itching
28 Amalgam (silver or mercury) fillings in my mouth.    Which tooth __________
29 Root canals.      Which tooth  __________
30 Metal crowns.   Which tooth  __________
31 Toothache.        Which tooth  __________
32 Periodontal or gum disease
33 Hemorrhoids
34 Excessive white clotted discharge
35a I am athletic    
35b I exercise regularly
37 Overweight
38 Thirsty

SECTION L
 1 Ring finger feels weak, sensitive, sore or painful
 2a I sometimes feel hot          
 2b I sometimes feel cold  
 2c I feel hot and cold in rotation
 3 Skin is discolored
 4 Pain all over my joints
 5 Migraine headaches ( in temple region)
 6 Headaches on top of head
 7 Pain on right side beneath rib
 8 Pain in abdominal / groin area
 9 Pain in outside (lateral side) of  feet
10 Pain or itching in genital region
11 Pain in back of head
12 Neck and shoulders are tight and sore
13 Irritable, impatient or indecisive
14a Depression        
14b Stressful lifestyle
15 Had stroke or brain damage
16 Get excited and lose self-control easily
17 Numbness in fingers
18a Difficult to fall asleep   
18b Wake up during the night 
19 Irregular bowel movements such as diarrhea and constipation in rotation
20a Mouth odor        
20b Armpit odor
21a Hemorrhoid    
21b Nasal bleeding
21c Gum bleeding 
21d Other bleeding __________
22a Frequently nauseated              
22b Bloated
22c Gassy
22d Experience reflux, belch or burp
23 Abdominal cramps before monthly menstrual cycle
24 Clumsy in physical motor functions
25 Take synthetic medications; have taken for _______ years
26a High cholesterol      
26b High triglyceride
27 Vision gradually degraded in recent months
28 Sneeze all year round or catch cold easily
29 Prostate problems; difficult urination or incontinence
30 Hernia in groin area
31 Dizziness
SECTION H
 1 Pain in both shoulders.  Left shoulder pain is more severe than the right
 2 Chest pain
 3 Pain in upper back region or around scapula
 4 Pain in armpit
 5 Palms sweat profusely; pain in palm of hands
 6 Sweat easily and profusely from armpit
 7 3rd and 5th fingers feel weak
 8 Heart palpitations
 9a Mind racing             
 9b Mental confusion
 9c Forgetfulness
10 Heart failure
11 Low or no energy; tire easily
12 Ulcers on tongue and other oral areas
13 Feel thirsty but don't want to drink

SECTION S
 1 Big toe or second toe feel weak
 2 Middle finger feels weak
 3a Knee pain        
 3b Knee swelling
 4 Pain in left side beneath ribs
 5 Heartburn (pain under sternum)
 6 Symptoms of TMJ joint in jaw
 7 Snore while sleeping
   8 Sclera (white part of eye) or palm is yellowish
 9 Poor appetite
10a Bloated stomach     
10b Gassy after eating
11a Stomach ulcer      
11b Ulcer in month
12 Retain water and fluids in stomach
13 Dry lips; thirsty all the time
14 Sweet taste in mouth
15 Get hungry easily
16a Can not move tongue easily    
16b Pain in tongue
17 Mind is always racing
18 Difficulty falling asleep
19 Wake up frequently 
20 Gum disease, especially in lower jaw
21 Periodontal disease
22 Had parasitic/fungal infection
SECTION P
 1 Thumb and index finger are weak and/or painful
 2 Gum disease, especially in upper jaw
 3 Toothaches in upper teeth
 4 Pain in elbow
 5 Asthma 
 6 Chronic cough
 7 Pain in right shoulder
 8a Emphysema       
8b Other lung disease______________
 9 Constipated 
10 Clumsy or awkward when using tools
11 Short of breath
12 Excessive sputum or phlegm

SECTION K
 1 Hungry, but don't have desire to eat
 2 Sleepy all the time
 3 Sclera (white of eye) is yellowish
 4 Vision is vague
 5 Feel frightened for no reason
 6 Dark facial and/or ear color
 7 Cramping in tendons
 8 Pain in lower back and sacrum area
 9 Knee pain
10 Pain in back of head
11 Abdominal pain
12 Pain and/or heat on bottom of feet
13 Dry skin, hair, eyes; hemorrhoids
14 Lack of sexual potency or desire
15 Infertile
16 Vaginal dryness, especially during intercourse
17 Vulva / vaginal itching
18 Wake up frequently during the night to go to the bathroom
19 Urinary accidents during sleep
20 Excessive white discharge from vaginal region
21 Hair loss
22 Yawn frequently
23 Periodontal disease
24 Brain disease
25 Bone and/or joint disease such as osteoporosis or arthritis
26 Water retention in ankles
27 Pain in Achilles tendon
28 Take birth control pills. Why? _________________
29 Hysterectomy
30 Replacement hormone therapy

For over 4,000 years, the Chinese have traditionally used herbal formulas to aid in recovery from various diseases and to promote abundant health.  These suggestions are for your education only.  Any suggestions we may make to assist your recovery are based on the information you provided.  They are not intended to diagnose, treat, cure or prevent any disease.  The decision to take any Chinese herbal formulas is up to you.  The Federal Drug Administration has not evaluated these formulas.  Please provide feedback two weeks after taking the formulas.

Please sign below to indicate your request for review of your medical information.

     Signature: ______________________________________________     Date: ____________

     Print your name: _________________________________________

May you be blessed with abundant health

 


Alternative Medicine Inc.
Copyright 1999 [Alternative Medicine Inc.]. All rights reserved.
Revised: December 14, 2004