EmailMe Form - Health Assessment Questionnaire v.10.0 (A)

Health Assessment Questionnaire v.10.0 (A)

Subscription Plan A

FOR SUBSCRIBERS ONLY
______________________
This Health Assessment Questionnaire is a part of Subscription to Low-Cost Naturopathic Health Service Plan A. The discounted fee for the questionnaire is US$42.00.

Health Assessment Questionnaire is an inventory of symptoms specific to the patient's health problems. The information derived from this questionnaire is an equivalent of a four-hour interview. The answers are processed by Dr. Kulisz's proprietary algorithm that generates numerical representation of the state of health, allowing for precise tracking of changes through the health improvement program.

After completing the questionnaire, click "SUBMIT". You will be transferred to the PayPal site to complete the payment. We will contact you soon.

Thank you for entrusting your health needs in us.

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Ver. 10.0

© Dr. Kulisz, 2023

First and last name *
First Last
New or established patient? *
Today's date *
MM / DD / YYYY
Age *
Full years
Gender *
Height *
In inches or centimeters
in/cm *
Select inches or centimeters
Weight *
Round up to full number
lbs/kilos *
Select pounds or kilos
Blood pressure *
Example: 130/80. Enter 999/99 if unknown.
Cholesterol (Enter 999 in all fields if unknown) *

Total LDL HDL

Cholesterol
How are you?
Please tell us how is your overall health comparing to previous assessment.
Phone *
No hyphens, no spaces. Non US and Canadian filers, please include country code.
Email *

Confirm
Referred by *
In the next field "Other", please tell us how did you find us if not referred by Dr. Kulisz or Dr. Dahlmann.
Other
Primary health concerns *
If none, write 'None"
Allergies *
If none, write "None"
Medications you are currently taking *
If none, write "None"
Are you pregnant? *
Yes
No
Do you use tobacco? *
Yes
No
Are you at risk for falls or falling injuries? *
Yes
No
In the following survey please rate symptoms that apply to you. If symptom does not apply to you, leave it marked "0" or "-"(default).
Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

	Total	LDL	HDL
Cholesterol

	1	2	3	4	0
1.1 Acid foods upset	1	2	3	4	-
1.2 Get chilled often	1	2	3	4	-
1.3 “Lump” in throat	1	2	3	4	-
1.4 Dry mouth, eyes, nose	1	2	3	4	-
1.5 Pulse speeds after meal	1	2	3	4	-
1.6 Keyed up, fail to calm	1	2	3	4	-
1.7 Cuts heal slowly	1	2	3	4	-
1.8 Gag easily	1	2	3	4	-
1.9 Unable to relax/startles easily	1	2	3	4	-
1.10 Extremities cold, clammy	1	2	3	4	-
1.11 Strong light irritates	1	2	3	4	-
1.12 Urine amout reduced	1	2	3	4	-
1.13 Heart pounds after retiring	1	2	3	4	-
1.14 “Nervous” stomach	1	2	3	4	-
1.15 Appetite reduced	1	2	3	4	-
1.16 Cold sweats often	1	2	3	4	-
1.17 Develops fever easily	1	2	3	4	-
1.18 Neuralgic pains	1	2	3	4	-
1.19 Staring, blinks little	1	2	3	4	-
1.20 Frequent sour stomach	1	2	3	4	-

Symptoms Group 2

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

	1	2	3	4	0
2.1 Stiff joints after wakeup	1	2	3	4	-
2.2 Leg cramps at night	1	2	3	4	-
2.3 “Butterfly” stomach, cramps	1	2	3	4	-
2.4 Watery eyes and/or nose	1	2	3	4	-
2.5 Eyes blink often	1	2	3	4	-
2.6 Swollen, puffy eyelids	1	2	3	4	-
2.7 Indigestion soon after meals	1	2	3	4	-
2.8 Always seem hungry; feels “lightheaded”	1	2	3	4	-
2.9 Rapid digestion	1	2	3	4	-
2.10 Frequent vomiting	1	2	3	4	-
2.11 Frequent hoarseness	1	2	3	4	-
2.12 Irregular breathing	1	2	3	4	-
2.13 Pulse slow; feels “irregular”	1	2	3	4	-
2.14 Gagging reflex	1	2	3	4	-
2.15 Difficulty swallowing	1	2	3	4	-
2.16 Alternating constipation, diarrhea	1	2	3	4	-
2.17 "Slow starter"	1	2	3	4	-
2.18 Frequent chills	1	2	3	4	-
2.19 Easily perspire	1	2	3	4	-
2.20 Poor circulation	1	2	3	4	-
2.21 Frequent colds, asthma, bronchitis	1	2	3	4	-

	1	2	3	4	0
3.1 Eat when nervous	1	2	3	4	-
3.2 Excessive appetite	1	2	3	4	-
3.3 Hungry between meals	1	2	3	4	-
3.4 Irritable when hungry	1	2	3	4	-
3.5 Trembling, “shaky” when hungry	1	2	3	4	-
3.6 Fatigued when hungry	1	2	3	4	-
3.7 Dizzy, lightheaded when hungry	1	2	3	4	-
3.8 Heart palpitations when hungry	1	2	3	4	-
3.9 Blurred vision, difficulty focusing eyesight when hungry	1	2	3	4	-
3.10 Afternoon headaches	1	2	3	4	-
3.11 "Sugar rush" from overeating sweets	1	2	3	4	-
3.12 Awaken after few hours sleep - hard to get back to sleep	1	2	3	4	-
3.13 Crave sweets or coffee	1	2	3	4	-
3.14 Moods of depression, “blues” or melancholy	1	2	3	4	-

Symptoms Group 4

	1	2	3	4	0
4.1 Hands and feet get numb easily	1	2	3	4	-
4.2 Sigh frequently, “air hunger”	1	2	3	4	-
4.3 Aware of “breathing heavily”	1	2	3	4	-
4.4 High altitude discomfort	1	2	3	4	-
4.5 Opens windows in closed room	1	2	3	4	-
4.6 Susceptible to colds and fevers	1	2	3	4	-
4.7 Afternoon “yawner”	1	2	3	4	-
4.8 Frequent drowsiness, lightheadedness	1	2	3	4	-
4.9 Swollen ankles, worse at night	1	2	3	4	-
4.10 Muscle cramps, worse during exercise; get “charley horses”	1	2	3	4	-
4.11 Shortness of breath on exertion	1	2	3	4	-
4.12 Dull pain in chest or radiating into left arm, worse on exertion	1	2	3	4	-
4.13 Bruise easily, “black and blue” spots	1	2	3	4	-
4.14 Tendency to anemia	1	2	3	4	-
4.15 Frequent nose bleeds	1	2	3	4	-
4.16 Noises in head, or ringing in ears	1	2	3	4	-
4.17 Tension under breastbone, or feeling of “tightness”, worse on exertion	1	2	3	4	-

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.
If the symptom does not apply to you, leave it marked "0" (default).

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

	1	2	3	4	0
5.1 Dizziness	1	2	3	4	-
5.2 Dry skin	1	2	3	4	-
5.3 Burning feet	1	2	3	4	-
5.4 Blurred vision	1	2	3	4	-
5.5 Itching skin and feet	1	2	3	4	-
5.6 Excessive falling hair, alopecia	1	2	3	4	-
5.7 Frequent skin rashes	1	2	3	4	-
5.8 Bitter, metallic taste in mouth in mornings	1	2	3	4	-
5.9 Bowel movements painful or difficult	1	2	3	4	-
5.10 Worrier, feels insecure	1	2	3	4	-
5.11 Feeling queasy; headache over eyes	1	2	3	4	-
5.12 Greasy foods upset	1	2	3	4	-
5.13 Stools light-colored	1	2	3	4	-
5.14 Skin peels on foot soles	1	2	3	4	-
5.15 Pain between shoulder blades	1	2	3	4	-
5.16 Use laxatives	1	2	3	4	-
5.17 Stools soft or watery	1	2	3	4	-
5.18 History of gallbladder attacks or gallstones	1	2	3	4	-
5.19 Sneezing attacks	1	2	3	4	-
5.20 Nightmares, bad dreams	1	2	3	4	-
5.21 Bad breath (halitosis)	1	2	3	4	-
5.22 Milk products cause distress	1	2	3	4	-
5.23 Sensitive to hot weather	1	2	3	4	-
5.24 Burning or itching anus	1	2	3	4	-
5.25 Crave sweets	1	2	3	4	-

	1	2	3	4	0
6.1 Lost taste for meat	1	2	3	4	-
6.2 Coated tongue	1	2	3	4	-
6.3 Indigestion after meal	1	2	3	4	-
6.4 Burning stomach, food relieves	1	2	3	4	-
6.5 Gas shortly after eating	1	2	3	4	-
6.6 Passing gas several hours after eating	1	2	3	4	-
6.7 Stomach “bloating” after meal	1	2	3	4	-
6.8 Passing large amounts of foul-smelling gas frequently	1	2	3	4	-
6.9 Mucous colitis or “irritable bowel” syndrome	1	2	3	4	-

	1	2	3	4	0
7.1 Insomnia	1	2	3	4	-
7.2 Nervousness	1	2	3	4	-
7.3 Can’t gain weight	1	2	3	4	-
7.4 Intolerance to heat	1	2	3	4	-
7.5 Emotional personality	1	2	3	4	-
7.6 Flush easily	1	2	3	4	-
7.7 Night sweats	1	2	3	4	-
7.8 Thin, moist skin	1	2	3	4	-
7.9 Inward trembling	1	2	3	4	-
7.10 Heart palpitations	1	2	3	4	-
7.11 Increased appetite without weight gain	1	2	3	4	-
7.12 Pulse fast at rest	1	2	3	4	-
7.13 Eyelids and/or face twitching	1	2	3	4	-
7.14 Irritable and restless	1	2	3	4	-
7.15 Can’t work under pressure	1	2	3	4	-

	1	2	3	4	0
8.1 Weight gain	1	2	3	4	-
8.2 Appetite decrease	1	2	3	4	-
8.3 Fatique easily	1	2	3	4	-
8.4 Ringing in ears	1	2	3	4	-
8.5 Sleepy during day/low energy	1	2	3	4	-
8.6 Sensitive to cold	1	2	3	4	-
8.7 Dry or scaly skin	1	2	3	4	-
8.8 Constipation	1	2	3	4	-
8.9 Mental "fog"/slugishness	1	2	3	4	-
8.10 Hair coarse, falls out	1	2	3	4	-
8.11 Headaches upon arising, wear off during day	1	2	3	4	-
8.12 Slow pulse, below 65	1	2	3	4	-
8.13 Frequent urination	1	2	3	4	-
8.14 Impaired hearing	1	2	3	4	-
8.15 Reduced initiative	1	2	3	4	-

	1	2	3	4	0
9.1 Failing memory	1	2	3	4	-
9.2 Low blood pressure	1	2	3	4	-
9.3 Increased sex drive	1	2	3	4	-
9.4 Headaches splitting/rendering type	1	2	3	4	-
9.5 Decreased sugar tolerance	1	2	3	4	-

Symptoms Group 10

Symptoms Group 10A Women

1 2 3 4 0

10.7 Adults: Menstrual disorders 1 2 3 4 -

10.8 Teens: Lack of menstruation 1 2 3 4 -
Mark 1 if the symptom is rare,
Mark 2 if the symptom is mild,
Mark 3 if the symptom is moderate,
Mark 4 ONLY if the symptom is severe,.
If the symptom does not apply to you, leave it marked "0" (default).

Symptoms Group 11A Women

1 2 3 4 0

11.6 Hair growth on face or body (female) 1 2 3 4 -

11.7 Masculine tendencies (female) 1 2 3 4 -
Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)

	1	2	3	4	0
10.1 Abnormal thirst	1	2	3	4	-
10.2 Bloated abdomen	1	2	3	4	-
10.3 Weight gain around hips or waist	1	2	3	4	-
10.4 Sex drive reduced or lacking	1	2	3	4	-
10.5 Tendency to ulcers, colitis	1	2	3	4	-
10.6 Increased sugar tolerance	1	2	3	4	-

	1	2	3	4	0
10.7 Adults: Menstrual disorders	1	2	3	4	-
10.8 Teens: Lack of menstruation	1	2	3	4	-

	1	2	3	4	0
11.1 Dizziness	1	2	3	4	-
11.2 Headaches	1	2	3	4	-
11.3 Hot flashes	1	2	3	4	-
11.4 Increased blood pressure	1	2	3	4	-
11.5 Sugar in urine (not diabetes)	1	2	3	4	-

	1	2	3	4	0
11.6 Hair growth on face or body (female)	1	2	3	4	-
11.7 Masculine tendencies (female)	1	2	3	4	-

	1	2	3	4	0
12.1 Weakness, dizziness	1	2	3	4	-
12.2 Chronic fatigue	1	2	3	4	-
12.3 Low blood pressure	1	2	3	4	-
12.4 Nails, weak, ridged	1	2	3	4	-
12.5 Tendency to hives	1	2	3	4	-
12.6 Arthritic tendencies	1	2	3	4	-
12.7 Perspiration increase	1	2	3	4	-
12.8 Bowel disorders	1	2	3	4	-
12.9 Poor circulation	1	2	3	4	-
12.10 Swollen ankles	1	2	3	4	-
12.11 Crave salt	1	2	3	4	-
12.12 Brown spots or bronzing of skin	1	2	3	4	-
12.13 Allergies - tendency to asthma	1	2	3	4	-
12.14 Weakness after colds, influenza	1	2	3	4	-
12.15 Physical/mental exhaustion	1	2	3	4	-
12.16 Respiratory disorders	1	2	3	4	-

	1	2	3	4	0
13.1 Accoustic hallucinations	1	2	3	4	-
13.2 Anorexia	1	2	3	4	-
13.3 Anxiety	1	2	3	4	-
13.4 Apprehension	1	2	3	4	-
13.5 Confusion	1	2	3	4	-
13.6 Craving for sweets	1	2	3	4	-
13.7 Depression	1	2	3	4	-
13.8 Distraction	1	2	3	4	-
13.9 Dizziness	1	2	3	4	-
13.10 Fatigue	1	2	3	4	-
13.11 Feeling something dreadful will happen	1	2	3	4	-
13.12 Forgetfulness	1	2	3	4	-
13.13 Headache	1	2	3	4	-
13.14 Hypochondria	1	2	3	4	-
13.15 Indigestion	1	2	3	4	-
13.16 Insomnia	1	2	3	4	-
13.17 Instability	1	2	3	4	-
13.18 Irritability	1	2	3	4	-
13.19 Morbid fears	1	2	3	4	-
13.20 Muscular soreness	1	2	3	4	-
13.21 Nervousness	1	2	3	4	-
13.22 Neuralgia (sharp pain that follows path of a nerve)	1	2	3	4	-
13.23 Neuritis (inflammation of a nerve, pain, and/or loss of reflexes)	1	2	3	4	-
13.24 Noise sensitivity	1	2	3	4	-
13.25 Poor appetite	1	2	3	4	-
13.26 Tendency to cry without reason	1	2	3	4	-
13.27 Weakness	1	2	3	4	-

Symptoms Group 14F -- Women only

	1	2	3	4	0
14F.1 Very easily fatigued	1	2	3	4	-
14F.2 Premenstrual tension	1	2	3	4	-
14F.3 Painful menses	1	2	3	4	-
14F.4 Depressed befor menstruation	1	2	3	4	-
14F.5 Prolonged, excessive menses	1	2	3	4	-
14F.6 Painful brests	1	2	3	4	-
14F.7 Menses too frequent	1	2	3	4	-
14F.8 Vaginal discharge	1	2	3	4	-
14F.9 Hysterectomy/ovaries removed	1	2	3	4	-
14F.10 Menopausal hot flashes	1	2	3	4	-
14F.11 Menses missed or scant	1	2	3	4	-
14F.12 Acne, worse at menses	1	2	3	4	-
14F.13 Depression of long standing	1	2	3	4	-

Symptoms Group 14M -- Men only

15. Additional information: *
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	1	2	3	4	0
14M.1 Prostate problems	1	2	3	4	-
14M.2 Urination difficult or dribbling	1	2	3	4	-
14M.3 Night urination frequent	1	2	3	4	-
14M.4 Depression	1	2	3	4	-
14M.5 Pain on inside of legs or heels	1	2	3	4	-
14M.6 Feeling of incomplete bowel evacuation	1	2	3	4	-
14M.7 Lack of energy	1	2	3	4	-
14M.8 Migrating aches and pains	1	2	3	4	-
14M.9 Tire too easily	1	2	3	4	-
14M.10 Avoids activity	1	2	3	4	-
14M.11 Leg nervousness at night	1	2	3	4	-
14M.12 Diminished sex drive	1	2	3	4	-

Version 10.0