Health Questionnaire

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Health Questionnaire

Questionnaire: Are you are eating the right foods for your body?

Score yourself for the following symptoms, indicating severity and/or frequency as follows:

1 – mild; 2 – moderate; 3 – severe. Leave blanks when answers do not apply.

Item Score
1 Frequent desire for sweet/quick energy foods – confectionery, honey, soft drinks etc
2 Fatigue relieved by eating or drinking
3 Tiredness in the mid or late afternoon
4 Chronic fatigue
5 Irritability before meals
6 Cups of tea/coffee per day. (Score 1 for 2 cups; score 2 for 3-5 cups; score 3 for 5+ cups)
7 Sugar or honey in tea/coffee. Score 1 for 1tsp; 2 for 2tsp; 3 for 3 tsp in either
8 Faintness when meals delayed
9 Headaches or “heavy head in between meals, morning or afternoon
10 Sleepy during the day or after meals
11 Chronic nervous exhaustion
12 Lack of energy
13 Fluctuating emotions
14 Need to eat often
15 Sleep disturbances – awaken after a few hours sleep or difficulty getting to sleep
16 Difficulty concentrating
17 Sluggish or lethargic in morning until after tea, coffee or breakfast
18 Episodes of dizziness or faintness
19 Periods of depression, “blues” or melancholy
20 Poor memory
21 Frequent anxiety
22 Worrier, feeling insecure
23 Need to drive oneself to get things done
24 Become tearful easily
25 Reduced initiative
26 Eat when nervous
27 Bad dreams or incessant dreaming
28 Cigarette smoking. 0-10 per day score 1; 11-20 per day score 2; 21+ per day score 3
29 Aware of breathing heavily
30 Episodic blurred or dulled vision
31 “Butterflies”, stomach cramps or hunger pains
32 Get shaky if hungry
33 Heart palpitates if meals missed or delayed
34 Hunger between meals
35 Inward trembling, tremors and/or cold sweats
36 Weakness spells
37 Magnify insignificant events
38 Blackouts or convulsions
39 Can’t decide easily
40 Bouts of anger or unreasonable behaviour
41 Feel better after breakfast
42 Above symptoms worse if premenstrual (women only)
43 Alcohol consumption. Less than once fortnightly score 0; 1-2 glasses per week score 1; average 1-3 glasses per day score 2; average 4+ glasses per day score 3
44 Allergies – tendencies to asthma, hay fever, skin rashes etc
45 Bleeding gums
46 Hallucinations
47 Cold hands and feet in winter
48 Difficulty in gaining weight
49 Tendency to gain weight easily
50 Decreased learning and memory
51 Confusion or forgetfulness
52 Restlessness
53 Suicidal tendencies
54 Vertigo distress
55 Tremor
56 Muscle pains, backache, leg cramping
57 Numbness
58 Staggering
59 Feelings of panic or loss of control
60 Itching or crawling sensations of the skin
61 Loss of libido (sex drive)
62 Nausea
63 Gastrointestinal distress (stomach upset)
64 Phobias
65 Symptoms of paranoia
66 Nervous breakdown (or fear of)
67 Hot flushes
68 Rheumatics – generalised aches and pains
                                                                                                                                                                                                                          Score
Total for items 01 – 17
Total for items 18 – 34
Total for items 35 – 51
Total for items 52 – 68
                                                                                                                                                                                                                Grand Total

You have now completed the test. Add each of the four subtotals individually and place the totals in the boxes provided above. Now add all four subtotals together to get your Grand Total and enter that into the box above.

Remember that a Total Score of 25 or more indicates that you are probably suffering from poor food choices and that a reassessment of your eating habits is suggested to enable you to reach an optimal level of health. No matter what your age.

You can find much more information on living a holistic lifestyle in these free magazines and on our YouTube channel.

David Lomman

Health Questionnaire

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