Health Survey

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Health Assessment Test

Take This Health Assessment Test FOR A FREE 15 MINUTE health educational PHONE CONVERSTAION

The symptoms listed in this questionnaire can help determine how the body functions. It is not a test to determine if you have a disease. For instance if a person gets gas after she eats then it’s possible that she needs more enzymes or she eats too much sugar. It does not determine if you have an ulcer. If a person gets light headed if she does not needs to eat every 2 hours it could mean that her ability to digest fat is slow or that she eats the wrong foods. It is not a test for diabetes. I look for patterns of symptoms and then we can talk about what those types symptoms could mean in any person's body. I talk in terms of what types of herbs, detoxification or pressure points would relate to people with those symptoms, but not you necessarily. This is an education not an examination; do not treat it as such. It is an educational conversation, a tool for you to understand how the body works, so that you can be more informed about the body works and to make better health choices. I may even recommend different books to read or how to gather more information. The things I talk about are based on physiology, Chinese medicine theory and nutritional theory. This is not FDA approved. It is thorough and detailed and you will really learn a lot. If you are looking for a diagnosis, you need to make an appointment either here or with your doctor, depending on your situation. Since this is educational only, I only need a first name, after the form is done you will be sent a way to schedule for the free conversation. If you are having a medical emergency dial 911

Consent*

I have read and agree with he above statement

Dr Stewart Edrich DC 3968 Cerritos Ave Los Alamitos, CA 90720

562-799-0320

Gender: *

Male

Female

Check if any of the following medications you are taking:

Antacids

Chemotherapy

Hormones

Relaxants/Sleeping Pills

Antibiotic/Antifunga

Cortisone Anti-Inflammatories

Laxatives

Recreational Drugs

Antidepressants

Diuretics

Lithium

Antidiabetic/Insulin

Heart Medications

Oral Contraceptive

Thyroid

Aspirin/Tylenol

High Blood Pressure

Radiation

Ulcer Medications

Other

Check if you eat, drink, or use:

Alcohol

Distilled Water

Luncheon Meats

Non-Herbal Teas

Candy

Fluoridated/Chlorinated Water

Margarine

Chew Tobacco

Carbonated Beverages

Eat at fast food restaurants regularly

Refined Sugars

Vitamins &Minerals

Cigarettes

Fried Foods

Milk Products

Coffee

Refined (White) Flour Products

Artificial Sweetner

Other

Check if you:

Diet often

Exercise Less than 3 times weekly

Are exposed to chemicals at work

Salt food without tasting

Are under excessive stress

Are exposed to cigarette smoke

Please List your five major health concerns in order of importance

Section A: Stomach/Digestion Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

1. Bad breath, halitosis

2. Loss of taste for high protein foods (meat, etc.)

3. Burning (acid) or nervous stomach,eating relieves

4. Gas shortly after eating

5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours

6. Difficulty digesting fruits or vegetables; undigested foods found in stools

7. Acid or spicy foods upset stomach

Section B: Liver, Gallbladder Stress

8. Lower bowel gas and or bloating several hours after eating

9. Feet burn

10. “Whites” of eyes (sclera) yellow

11. Dry skin, itchy feet and /or skin peels on feet

12. Brown spots or bronzing of skin

13. Bitter metallic taste in mouth

14. Blurred vision

15. Headache over eyes

16. Feel nauseous, queasy or gag easily

17. Color of stools light brown or yellow

18. Greasy or high fat foods cause distress

19. Pain between shoulder blades

20. Dark circles under eyes

21. “Acid” breath

22. History of gallbladder attacks or gallstones Or gallbladder removed

23. Appetite reduced

Section C: Intestinal Stress

24. Coated tongue or “fuzzy” debris on tongue

25. Pass large amounts of foul smelling gas

26. Irritable bowel or mucous colitis

27. Constipation, diarrhea alternating or stools alternate from soft to watery

28. Bowel movements painful or difficult, constipation, and/or laxatives used

29. Burning or itching anus

Allergic Stress

30. Head congestion/sinus fullness

31. Sneezing attacks

32. Dreaming, nightmare-like bad dreams

33. Milk products and/or wheat products cause distress

34. Eyes and nose watery

35. Eyes swollen or puffy

36. Pulse speeds after meals and/or heart pounds after retiring

Section: D: Blood Sugar Stress

37. Crave sweets or coffee in afternoon or mid-morning

38. Hungry between meals or excessive appetite

39. Overeating sweets upsets

40. Eat when nervous

41. Irritable before meals

42. Get “shaky” or light-headed if meals delays

43. Fatigue, eating relieves

44. Heart palpitates if meals missed or delayed

45. Awaken a few hours after sleep, hard to get back to sleep

Section: E: Vitamin Deficiency

46. Muscle soreness after moderate exercise

47. Vulnerability to insect bites (especially fleas and mosquitoes)

48. Loss of muscle tone or “heaviness” in arms or legs

49. Enlarged heart and/or heart failure

50. Worried, feel insecure and/or highly emotional

51. Pulse slow/below 65 or irregular pulse

Section: F: Pituitary Hormone Stress

52. Sex drive increased

53. “Splitting” type headaches

54. Memory failing

55. Tolerance for sugar reduced

Section: G: Pituitary Hormone Fatigue

56. Sex drive reduced or absent

57. Abnormal thirst

58. Weight gain around hips or waist

59. Tendency to ulcers or colitis

60. Increased ability to eat sugar without symptoms

61. Menstrual disorders (women)

62. Lack of menstruation (young girls)

Section: H: Thyroid Stress

63. Difficulty gaining weight, even if large appetite

64. Heart palpitations

65. Nervous, emotional, and/or can't work under pressure

66. Insomnia

67. Inward trembling

68. Night sweats

69. Fast pulse at rest

70. Intolerant to high temperatures

71. Easily flushed

Section: I: Thyroid Fatigue

72. Difficulty losing weight

73. Reduced initiative and/or mental sluggishness

74. Easily fatigued, sleepy during the day

75. Sensitive to cold, poor circulation (cold hands and feet)

76. Dry or scaly skin

77. “Ringing” in ears/noises in head

78. Hearing impaired

79. Constipation

80. Excessive falling hair and/or coarse hair

81. Headaches when awaken/wear off during day

Section: J: Adrenal Stress

82. Blood pressure increased

83. Headaches

84. Hot flashes

85. Hair growth on face or body (women)

86. Masculine tendencies (women)

Section: K: Adrenal Fatigue

87. Blood pressure low

88. Crave salt

89. Chronic fatigue/get drowsy

90. Afternoon yawning

91. Weakness/dizziness

92. Weakness after colds/slow recovery

93. Circulation poor

94. Muscular and nervous exhaustion

95. Subject to colds, asthma, bronchitis (respiratory disorders)

96. Allergies and/or hives

97. Difficulty maintaining manipulative correction

98. Arthritic tendencies

99. Nails weak, ridged

100. Perspire easily

101. Slow starter in morning

102. Afternoon headaches

Section: L: Mineral depletion

103. Frequent skin rashes and/or hives

104. Muscle-leg-toe cramping at rest and/or while sleeping

105. Fever easily raised/fevers common

106. Crave chocolate

107. Feet have bad odor

108. Hoarseness frequent

109. Difficulty swallowing

110. Joint stiffness after rising

111. Vomiting frequent

112. Tendency to anemia

113. “Whites” of eyes (sclera) blue

114. “Lump” in throat

115. Dry mouth-eyes-nose

116. White spots on finger nails

117. Cuts heal slowly and/or scar easily

118. Reduced or “lost” sense of taste and/or smell

119. Susceptible to colds, fevers, and/or infections

120. Strong light irritates eyes

121. Noises in head or ringing in ears

122. Burning sensations in mouth

123. Numbness in hands and feet (extremities “ go to sleep”)

124. Intolerant to monosodium glutamate (MSG)

125. Cannot recall dreams

126. Nose bleeds frequent

127. Bruise easily, “black and blue” spots

128. Muscle cramps, worse with exercise (“charley horses” )

Section M: Cardio Vascular Stress

129. Aware of heavy and/or irregular breathing

130. Discomfort in high altitudes

131. “Air hunger”/ sigh frequently

132. Swollen ankles/worse at night

133. Shortness of breath with exertion

134. Dull pain in chest and/or pain radiating into left arm, worse on exertion

Female Hormone Stress

Female Only

135. Premenstrual tension

136. Painful menses (cramping, etc.)

137. Menstruation excessive or prolonged

138. Painful/tender breasts

139. Menstruate too frequently

140. Acne, worse at menses

141. Depressed feelings before menstruation

142. Vaginal discharge

143. Menses scanty or missed

144. Hysterectomy/ovaries removed

145. Menopausal hot flashes

146. Depression

Male Hormone Stress

Men Only

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year. Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

147. Prostate trouble

148. Urination difficult or dribbling

149. Night urination frequent

150. Pain on inside of legs or heels

151. Feeling of incomplete bowel evacuation

152. Leg nervousness at night

153. Tire easily/avoid activity

154. Reduced sex drive

155. Depression

156. Migrating aches and pains

Is there anything else youe would like to say?

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