Health Assessment Questionnaire

Name:___________________________________________ Date:__________________

Please check box if you have any of these signs & symptoms

Stomach pains

Abdominal pains

Sudden acute indigestion or heartburn

Relief of gastric symptoms by carbonated beverages

Relief of stomach pain by drinking cream/milk

Black color stool

History of gastric ulcer

Currently have gastric ulcer

Alternating diarrhea and constipation

Lower abdominal pain or cramps

Straining at defecation

Long Term use of laxatives

Excessive gas

Hemorrhoids

History of being diagnosed with Irritable bowl

Diverticulitis, colon polyps, hemorrhoids

Yellow in white of eyes

Body odor

Mental confusion

Less than one bowel movement a day

History of alcohol use or chemotherapy

Blood test showing elevated liver enzymes

History of hepatitis

Fluid retention in arms and legs

Dry , itchy skin

Frequent urge to urinate

Consume less than 8 glasses of water a day

Cloudy urine

Strong smelling urine

High blood pressure

Thick skin and fingernails

Dry skin

Sensitivity to cold

Cold hands and feet

Chronic fatigue

Trouble waking up in the morning

Low sex drive

Irritability and mood swings caused by sugar

Thinning or loss of outside portion of eyebrow

Easy weight gain

Slow reflexes

Inflamed or bleeding gums

Runny nose

Frequent throat infection

Cold sores

Poor wound healing

Slow recovery from colds or flu

More than 2 colds or flu per year

Suffering from Chronic infection

History of Cancer

Entire body is painful to touch

Swollen joints

Food sensitivity or allergy

Chronic join or inflammation

Hay fever symptoms ( nasal discharge, eye itch)

Chronic sinusitis

Shortness of breath at rest

Chest pain while walking

Missed beats or extra heart beats

Swelling of feet and ankles

Diagonal earlobe crease ( wrinkle)

High blood pressure ( > 140/90)

Total cholesterol above 215

Cold hand and feet

Slurred speech

Cramps in calf muscle while walking

Numbness in extremities

Poor concentration

Ringing in the years

Pain in back of head and next when getting up in the morning

Feeling of heaviness in the head

Loss of balance

Dizziness

Ringing in the ears

Trembling hands

Loss of grip strength

Tingling pain sensation

Lack of coordination

Proneness to accident

Loss of muscle tone

Need for 10-12 hours of sleep

History of convulsion

Swollen knees/elbow

History of joint injury

Bursitis

Tendonitis

Join pain/ arthritis

Morning stiffness

Enlarged joints, especially on hands

Painful join during humid weather conditions

Muscle spasm

Tightness of shoulder muscle

Muscle cramps

Leg cramps at night

Stiffness all over

Stiffness in the morning

Inability to sit straight

Muscle Weakness

Dry hair and scalp

Week, brittle or cracked nails

Cracked or dry lips

Thin skin

Lack of radiant of hair and skin

Forgetfulness

Reduced memory

Explanation in detail of the box checked.

Diet Questionnaire

Please circle the relevant answer.

Diet Profile

Grains

1

What kind of bread do you use?

Whole Grain

White

2

How many slices of bread or dinner rolls you use daily?

0

1

2

3

4

>5

3

How often do you have cereal a week?

Never

1

2

3

4

>5

4

How often do you have pancakes?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

5

How often do you have noodles a week?

Never

1

2

3

4

>5

6

How often do you eat rice a week?

Never

1

2

3

4

>5

Protein

7

Are you a vegetarian?

yes

no

8

How often do you eat tofu?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

9

How often do you eat legumes?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

Meat

If you are a vegetarian, skip the next 4 questions

10

How often do you eat pork a week?

Never

1

2

3

4

>5

11

How often do you eat beef a week?

Never

1

2

3

4

>5

12

How often do you eat chicken a week?

Never

1

2

3

4

>5

13

How often do you eat fish a week?

Never

1

2

3

4

>5

Fruits

14

How many fresh fruits do you eat daily?

0

1

2

3

4

>5

15

How many glasses of fruit juice do you drink per day?

0

1

2

3

4

>5

16

How often do you eat oranges?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

Vegetables

17

How many servings of cooked vegetables (1/2 cup) do you eat daily?

0

1

2

3

4

>5

18

How often do you take green leafy vegetables (not salad)?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

19

How often do you take salad?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

Beverages

20

How many cups of coffee do you drink a day?

0

1

2

3

4

>5

21 How many cups of tea do you drink a day?
0

1

2

3

4

>5

22 How many tea spoon of sugar you add for your tea or coffee?
0

1

2

3

4

>5

23 How many cola drinks do you drink a week?
0

1-2

3-4

5-6

7-8

>9

24 How many soft drinks do you drink a week?
0

1-2

3-4

5-6

7-8

>9

25 How many alcoholic beverages do you take a week?
0

1-2

3-4

5-6

7-8

>9

Desserts

26
How often do you take cakes/pies/cookies?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

27
How often do you take ice cream/shakes?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

28
How often do you take candies or sweets?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

Dairy Products

29

How many cups of milk do you drink a day?

0

1

2

3

4

>5

30

How often do you take cheese?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

31

How often do you take yogurt?

Never

1 time per month

1 time every 2 weeks

1 time per week

2 times per week

daily

Lifestyle

32
How often do you dine out?

0

1

2

3

4

>5

33
How often do you dine in a fast food restaurant?

0

1

2

3

4

>5

34
How often do you dine in a hawker center or Food Junction?

0

1

2

3

4

>5

35
Do you add salt or soy sauce at the table?

yes

no

	Stomach pains
	Abdominal pains
	Sudden acute indigestion or heartburn
	Relief of gastric symptoms by carbonated beverages
	Relief of stomach pain by drinking cream/milk
	Black color stool
	History of gastric ulcer
	Currently have gastric ulcer

	Alternating diarrhea and constipation
	Lower abdominal pain or cramps
	Straining at defecation
	Long Term use of laxatives
	Excessive gas
	Hemorrhoids
	History of being diagnosed with Irritable bowl
	Diverticulitis, colon polyps, hemorrhoids

	Yellow in white of eyes
	Body odor
	Mental confusion
	Less than one bowel movement a day
	History of alcohol use or chemotherapy
	Blood test showing elevated liver enzymes
	History of hepatitis

	Fluid retention in arms and legs
	Dry , itchy skin
	Frequent urge to urinate
	Consume less than 8 glasses of water a day
	Cloudy urine
	Strong smelling urine
	High blood pressure

	Thick skin and fingernails
	Dry skin
	Sensitivity to cold
	Cold hands and feet
	Chronic fatigue
	Trouble waking up in the morning
	Low sex drive
	Irritability and mood swings caused by sugar
	Thinning or loss of outside portion of eyebrow
	Easy weight gain
	Slow reflexes

	Inflamed or bleeding gums
	Runny nose
	Frequent throat infection
	Cold sores
	Poor wound healing
	Slow recovery from colds or flu
	More than 2 colds or flu per year
	Suffering from Chronic infection
	History of Cancer

	Entire body is painful to touch
	Swollen joints
	Food sensitivity or allergy
	Chronic join or inflammation
	Hay fever symptoms ( nasal discharge, eye itch)
	Chronic sinusitis

	Shortness of breath at rest
	Chest pain while walking
	Missed beats or extra heart beats
	Swelling of feet and ankles
	Diagonal earlobe crease ( wrinkle)
	High blood pressure ( > 140/90)
	Total cholesterol above 215

	Cold hand and feet
	Slurred speech
	Cramps in calf muscle while walking
	Numbness in extremities
	Poor concentration
	Ringing in the years
	Pain in back of head and next when getting up in the morning

	Feeling of heaviness in the head
	Loss of balance
	Dizziness
	Ringing in the ears
	Trembling hands
	Loss of grip strength
	Tingling pain sensation
	Lack of coordination
	Proneness to accident
	Loss of muscle tone
	Need for 10-12 hours of sleep
	History of convulsion

	Swollen knees/elbow
	History of joint injury
	Bursitis
	Tendonitis
	Join pain/ arthritis
	Morning stiffness
	Enlarged joints, especially on hands
	Painful join during humid weather conditions

	Muscle spasm
	Tightness of shoulder muscle
	Muscle cramps
	Leg cramps at night
	Stiffness all over
	Stiffness in the morning
	Inability to sit straight
	Muscle Weakness

	Dry hair and scalp
	Week, brittle or cracked nails
	Cracked or dry lips
	Thin skin
	Lack of radiant of hair and skin

Diet Profile
	Grains
1	What kind of bread do you use?		Whole Grain	White
2	How many slices of bread or dinner rolls you use daily?	0	1	2	3	4	>5
3	How often do you have cereal a week?	Never	1	2	3	4	>5
4	How often do you have pancakes?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
5	How often do you have noodles a week?	Never	1	2	3	4	>5
6	How often do you eat rice a week?	Never	1	2	3	4	>5
	Protein
7	Are you a vegetarian?		yes	no
8	How often do you eat tofu?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
9	How often do you eat legumes?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
	Meat
	If you are a vegetarian, skip the next 4 questions
10	How often do you eat pork a week?	Never	1	2	3	4	>5
11	How often do you eat beef a week?	Never	1	2	3	4	>5
12	How often do you eat chicken a week?	Never	1	2	3	4	>5
13	How often do you eat fish a week?	Never	1	2	3	4	>5
	Fruits
14	How many fresh fruits do you eat daily?	0	1	2	3	4	>5
15	How many glasses of fruit juice do you drink per day?	0	1	2	3	4	>5
16	How often do you eat oranges?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
	Vegetables
17	How many servings of cooked vegetables (1/2 cup) do you eat daily?	0	1	2	3	4	>5
18	How often do you take green leafy vegetables (not salad)?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
19	How often do you take salad?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
	Beverages
20	How many cups of coffee do you drink a day?	0	1	2	3	4	>5
21	How many cups of tea do you drink a day?	0	1	2	3	4	>5
22	How many tea spoon of sugar you add for your tea or coffee?	0	1	2	3	4	>5
23	How many cola drinks do you drink a week?	0	1-2	3-4	5-6	7-8	>9
24	How many soft drinks do you drink a week?	0	1-2	3-4	5-6	7-8	>9
25	How many alcoholic beverages do you take a week?	0	1-2	3-4	5-6	7-8	>9
	Desserts
26	How often do you take cakes/pies/cookies?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
27	How often do you take ice cream/shakes?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
28	How often do you take candies or sweets?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
	Dairy Products
29	How many cups of milk do you drink a day?	0	1	2	3	4	>5
30	How often do you take cheese?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
31	How often do you take yogurt?	Never	1 time per month	1 time every 2 weeks	1 time per week	2 times per week	daily
	Lifestyle
32	How often do you dine out?	0	1	2	3	4	>5
33	How often do you dine in a fast food restaurant?	0	1	2	3	4	>5
34	How often do you dine in a hawker center or Food Junction?	0	1	2	3	4	>5
35	Do you add salt or soy sauce at the table?		yes	no

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