Health Assessment Questionnaire v.10.0
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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 cost of the questionnaire is US$60.00.* 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.

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World-Wide Naturopathic Health Service

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IMPORTANT NOTICE: There is a short telephone/Internet consultation included in the fee for Health Assessment Questionnaire. However, there is a separate fee for a full consultation (hour to an hour-and-half; office or Internet) – should it be required, subject to patient’s approval. There is no obligation of any kind whatsoever, to request such a consultation or to buy any naturopathic formulations, remedies, or supplements from our dispensary. For more information go to http://www.kulisz.com/practice/office-fees/
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Ver. 10.0
  • / /
  • Full years
  • In inches or centimeters
  • Select inches or centimeters
  • Round up to full number
  • Select pounds or kilos
  • Example: 130/80. Enter 999/99 if unknown.
  • Total LDL HDL
    Cholesterol
  • Please tell us how is your overall health comparing to previous assessment.
  • No hyphens, no spaces. Non US and Canadian filers, please include country code.
  • In the next field "Other", please tell us how did you find us if not referred by Dr. Kulisz or Dr. Dahlmann.
  • If none, write 'None"
  • If none, write "None"
  • If none, write "None"
  • 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,.
  • 1 2 3 4 0
    1.1 Acid foods upset
    1.2 Chills
    1.3 “Lump” in throat
    1.4 Dry mouth, eyes, nose
    1.5 Pulse speeds after meal
    1.6 Easily irritable, difficult to calm
    1.7 Cuts heal slowly
    1.8 Gag easily
    1.9 Unable to relax/startles easily
    1.10 Extremities cold, clammy
    1.11 Strong light irritates
    1.12 Urine amout reduced
    1.13 Heart pounds after retiring
    1.14 “Nervous” stomach
    1.15 Appetite reduced
    1.16 Cold sweats
    1.17 Develops fever easily
    1.18 Neuralgic pains
    1.19 Staring, blinks little
    1.20 Frequent sour stomach
  • 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
    2.2 Leg cramps at night
    2.3 “Butterfly” stomach, cramps
    2.4 Watery eyes and/or nose
    2.5 Eyes blink often
    2.6 Swollen, puffy eyelids
    2.7 Indigestion soon after meals
    2.8 Always seem hungry; feels “lightheaded”
    2.9 Rapid digestion
    2.10 Frequent vomiting
    2.11 Frequent hoarseness
    2.12 Irregular breathing
    2.13 Pulse slow; feels “irregular”
    2.14 Gagging reflex
    2.15 Difficulty swallowing
    2.16 Alternating constipation, diarrhea
    2.17 "Slow starter"
    2.18 Chills
    2.19 Easily perspire
    2.20 Poor circulation
    2.21 Subject to colds
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    3.1 Eat when nervous
    3.2 Excessive appetite
    3.3 Hungry between meals
    3.4 Irritable when hungry
    3.5 Trembling, “shaky” when hungry
    3.6 Fatigued when hungry
    3.7 Dizzy, lightheaded when hungry
    3.8 Heart palpitations when hungry
    3.9 Blurred vision, difficulty focusing eyesight when hungry
    3.10 Afternoon headaches
    3.11 "Sugar rush" from overeating sweets 
    3.12 Awaken after few hours sleep - hard to get back to sleep
    3.13 Crave sweets or coffee
    3.14 Depressed moods
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    4.1 Hands and feet get numb easily
    4.2 Sigh frequently, “air hunger”
    4.3 Aware of “breathing heavily”
    4.4 High altitude discomfort
    4.5 Opens windows in closed room
    4.6 Susceptible to colds and fevers
    4.7 Afternoon “yawner”
    4.8 Drowsiness, lightheadedness
    4.9 Swollen ankles, worse at night
    4.10 Muscle cramps, worse during exercise
    4.11 Shortness of breath on exertion
    4.12 Dull pain in chest or radiating into left arm, worse on exertion
    4.13 Bruise easily, “black and blue” spots
    4.14 Tendency to anemia
    4.15 Frequent nose bleeds
    4.16 Noises in head, or ringing in ears
    4.17 Tension under breastbone, or feeling of “tightness”, worse on exertion
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    5.1 Dizziness
    5.2 Dry skin
    5.3 Burning feet
    5.4 Blurred vision
    5.5 Itching skin and feet
    5.6 Excessive falling hair, alopecia
    5.7 Frequent skin rashes
    5.8 Bitter, metallic taste in mouth in mornings
    5.9 Bowel movements painful or difficult
    5.10 Worrier, feels insecure
    5.11 Feeling queasy; headache over eyes
    5.12 Greasy foods upset
    5.13 Stools light-colored
    5.14 Skin peels on foot soles
    5.15 Pain between shoulder blades
    5.16 Use laxatives
    5.17 Stools soft or watery
    5.18 History of gallbladder attacks or gallstones
    5.19 Sneezing attacks
    5.20 Nightmares, bad dreams
    5.21 Bad breath (halitosis)
    5.22 Lactose intolerance
    5.23 Sensitive to hot weather
    5.24 Burning or itching anus
    5.25 Crave sweets
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    6.1 Lost taste for meat
    6.2 Coated tongue
    6.3 Indigestion after meal
    6.4 Burning stomach, food relieves
    6.5 Gas shortly after eating
    6.6 Passing gas several hours after eating
    6.7 Stomach “bloating” after meal
    6.8 Passing large amounts of foul-smelling gas frequently
    6.9 Mucous colitis or “irritable bowel” syndrome
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    7.1 Insomnia
    7.2 Nervousness
    7.3 Can’t gain weight
    7.4 Intolerance to heat
    7.5 Emotional personality
    7.6 Flush easily
    7.7 Night sweats
    7.8 Thin, moist skin
    7.9 Inward trembling
    7.10 Heart palpitations
    7.11 Increased appetite without weight gain
    7.12 Pulse fast at rest
    7.13 Eyelids and/or face twitching
    7.14 Irritable and restless
    7.15 Can’t work under pressure
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    8.1 Weight gain
    8.2 Appetite decrease
    8.3 Fatique easily
    8.4 Ringing in ears
    8.5 Sleepy during day/low energy
    8.6 Sensitive to cold
    8.7 Dry or scaly skin
    8.8 Constipation
    8.9 Mental "fog"/slugishness
    8.10 Hair coarse, falls out
    8.11 Headaches upon arising, wear off during day
    8.12 Slow pulse, below 65
    8.13 Frequent urination
    8.14 Impaired hearing
    8.15 Reduced initiative
  • 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).
  • 1 2 3 4 0
    9.1 Failing memory
    9.2 Low blood pressure
    9.3 Increased sex drive
    9.4 Headaches splitting/rendering type
    9.5 Decreased sugar tolerance
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    10.1 Abnormal thirst
    10.2 Bloated abdomen
    10.3 Weight gain around hips or waist
    10.4 Sex drive reduced or lacking
    10.5 Tendency to ulcers, colitis
    10.6 Increased sugar tolerance
  • 1 2 3 4 0
    10.7 Adults: Menstrual disorders
    10.8 Teens: Lack of menstruation
  • 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).
  • 1 2 3 4 0
    11.1 Dizziness
    11.2 Headaches
    11.3 Hot flashes
    11.4 Increased blood pressure
    11.5 Sugar in urine (not diabetes)
  • 1 2 3 4 0
    11.6 Hair growth on face or body (female)
    11.7 Masculine tendencies (female)
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    12.1 Weakness, dizziness
    12.2 Chronic fatigue
    12.3 Low blood pressure
    12.4 Nails, weak, ridged
    12.5 Tendency to hives
    12.6 Arthritic tendencies
    12.7 Perspiration increase
    12.8 Bowel disorders
    12.9 Poor circulation
    12.10 Swollen ankles
    12.11 Crave salt
    12.12 Brown spots or bronzing of skin
    12.13 Allergies - tendency to asthma
    12.14 Weakness after colds, influenza
    12.15 Physical/mental exhaustion
    12.16 Respiratory disorders
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    13.1 Accoustic hallucinations
    13.2 Anorexia
    13.3 Anxiety
    13.4 Apprehension
    13.5 Confusion
    13.6 Craving for sweets
    13.7 Depression
    13.8 Distraction
    13.9 Dizziness
    13.10 Fatigue
    13.11 Feeling something dreadful will happen
    13.12 Forgetfulness
    13.13 Headache
    13.14 Hypochondria
    13.15 Indigestion
    13.16 Insomnia
    13.17 Instability
    13.18 Irritability
    13.19 Morbid fears
    13.20 Muscular soreness
    13.21 Nervousness
    13.22 Neuralgia (sharp pain that follows path of a nerve)
    13.23 Neuritis (inflammation of a nerve, pain, and/or loss of reflexes)
    13.24 Noise sensitivity
    13.25 Poor appetite
    13.26 Tendency to cry without reason
    13.27 Weakness
  • Symptom rating: Rare – 1, Mild – 2, Moderate – 3, Severe – 4, Not applicable – 0 or “-“(default)
  • 1 2 3 4 0
    14F.1 Very easily fatigued
    14F.2 Premenstrual tension
    14F.3 Painful menses
    14F.4 Depressed befor menstruation
    14F.5 Prolonged, excessive menses
    14F.6 Painful brests
    14F.7 Menses too frequent
    14F.8 Vaginal discharge
    14F.9 Hysterectomy/ovaries removed
    14F.10 Menopausal hot flashes
    14F.11 Menses missed or scant
    14F.12 Acne, worse at menses
    14F.13 Depression of long standing
  • 1 2 3 4 0
    14M.1 Prostate problems
    14M.2 Urination difficult or dribbling
    14M.3 Night urination frequent
    14M.4 Depression
    14M.5 Pain on inside of legs or heels
    14M.6 Feeling of incomplete bowel evacuation
    14M.7 Lack of energy
    14M.8 Migrating aches and pains
    14M.9 Tire too easily
    14M.10 Avoids activity
    14M.11 Leg nervousness at night
    14M.12 Diminished sex drive
  • Write here questions you want ask and provide additional information that you feel is pertinent to your health. If none, type "None"
Version 10.0