Health Appraisal Questionnaire

Sutton BioEnergetix Health Services

Health Appraisal Questionnaire

The cost of this questionnaire is $75.00, plus $20 for each formula.


Format: 123-456-7890

The information in this questionnaire is used to determine energetic imbalances only. It is not a substitute for modern medicine nor will the information be used to treat any condition. If you feel you have a condition that needs medical attention, do not use this or anything that you learn from this or anyone from Sutton BioEnergetix Health Services, Inc. as a substitute for proper medical attention. The recommendations that will be given will be for things that will help correct these energetic imbalances. To acknowledge that you read and understand this check the box below (checking the box is needed to continue).

Part I

Section A:

1
Temperature Sensitivity
2
Hypersensitive to Odors/Chemicals
3
Excessive/Deficient Appetite
4
Chronic Headache
5
Recurrent Dizziness/Light Headedness
6
Memory Problems
7
Chronic Hot or Cold Flashes
8
Type A Behavior/Outbursts
9
Excessive Thirst
10
Excessive Sleep or Insomnia
11
History of Heart Disease
12
High or Low Blood Pressure
13
History of Birth Defects
14
Multiple Birth Defects
15
Exceptional Number of Fevers
16
Diminished or Loss Sense of Smell
17
Chronic Spontaneous Abortions
18
Decreased/Excessive Sex Drive
19
Seizures/Convulsions

Section B:

1
Decreased Scalp Hair
2
Increased Body Hair
3
Chronic Headaches
4
Crave Protein
5
Extreme Loss of Energy
6
Menstrual Irregularities
7
Dry or Oily Skin/Hair
8
Hyper Pigmentation of Skin
9
Visual Disturbances
10
Hyperactivity/Chronic Fatigue
11
Water Retention
12
Psychological Disturbances
13
Impotence
14
Hyper/Hypoglycemia
15
Under 4'10 or over 6'10
16
Large or Small Boned
17
Use Birth Control Pill/Hormones
18
Infertility
19
Delayed Sexual Development

Section C:

1
Increased Sensitive to the Environment
2
Migraine Headaches
3
Epileptic Seizures
4
Emotional Ups & Downs
5
Multple Allergies
6
Impotency
7
Reduced Sexual Drive
8
Excessive Sexual Drive
9
Recurrent Anxiety
10
Visual Problems
11
Dull/Exaggerated Senses
12
Extremely Sensitive to Sunlight
13
History of Sever Shock/Trauma
14
Recurrent Fatigue
15
Menstrual Disturbances
16
Fatigue During Winter Months
17
Infertility
18
Early Sexual Development
19
Abnormal Sleep Patterns

Section D:

1
Loss of Balance
2
Ringing/Buzzing in Ears
3
Trembling Hands
4
Loss of Feeling in Hands and/or Feet
5
Limbs Feel Heavy to Hold Up
6
Loss of Grip Strength
7
Tingling Pain Sensation
8
In Coordination
9
Nervousness
10
Nightmares
11
Intense Dreams
12
Leg Cramps/Restless Legs at Night
13
Restless/Uneasy Sleeper
14
Stroke
15
Accident Prone
16
Loss of Muscle Tone
17
Neurological Disorder
18
Have Shingles
19
Psychiatric Disorder
20
Use of Psycho-Pharmaceutical Drugs
21
Sleep Walk

Part II

Section A:

1
Frequent Urinations
2
Frequent Kidney/Bladder Infections
3
Rarely Need to Unrinate
4
Painful/Burning When Urinating
5
Difficulty Passing Urine
6
Dripping After Urinating
7
Can't Hold Urine
8
Rose Colored (Bloody) Urine
9
Cloudy Urine
10
Strong Smelling Urine
11
Water Retention/Bloating
12
Flushed Skin
13
Blue Nose, Fingers, Toes
14
Chronic Headache
15
Heart/Circulatory Problems
16
Excessive Thirst/Dehydration
17
Joint Swelling
18
History of Kidney Disorders
19
Miscarriage/Delivery Problems
20
Hemmorrhoids
21
High Blood Pressure
22
Crave Salt
23
Breast Feeding Difficulties
24
Menstrual Problems
25
Use of Diuretics

Section B:

1
Little Urinary Output
2
Unexplained Weight Gain
3
Water Retention/Leg Swelling
4
Edema (Swelling) Around Eyes & Face
5
Headaches & Fatigue
6
Visual Difficulties
7
Blood in the Urine
8
Smoky or "Coke-Colored" Urine
9
Abdominal Pain or Swelling
10
Lower Back Pain
11
Repeated Night Time Urination
12
Nausea or Loss of Appetite
13
Urgency or Frequency of Urinating
14
Painful Urination
15
Anemia
16
High Blood Pressure
17
History of Kidney Disease or Infection
18
Protein or White Blood Cells in Urine
19
History of Strep Throat
20
History of Kidney Stones
21
Fever of Undetermined Origin
22
History of Diabetes
23
Pressure or Swelling Above Public Bone
24
History of Prostate Infection/Swelling
25
History of Congestive Heart/Liver Disease
26
Use of Diuretics

Part III

Section A:

1
Swollen Eyes (Bulging)
2
Thick Skin and Fingernails
3
Dry Skin
4
Sensitive to the Cold
5
Cold Hands and Feet
6
Excessive Menstrual Bleeding
7
Chronic Fatigue
8
Heart Palpitations/Hyperactivity
9
Depressed/Apathetic
10
Decreased Sex Drive
11
Puffy/Wrinkly Skin
12
Sugar Cases Irritability/Mood Swings
13
Premenstrual Tension
14
Constipation/Chronic Diarrhea
15
Heart Intolerance
16
Changes in Hair Texture
17
Gain or Lose Weight Easily
18
Anemia Unaffected by Iron
19
Auxiliary Temperature Below 97.6%
20
Slow Reflexes
21
Take Thyroid Medication
22
Present Thyroid Condition

Part IV

Section A:

1
Sensitive to Exhaust Fumes, Smoke, Smog and Petrochemicals
2
Periodic Constipation/Diarrhea
3
Cannot Tolerate Much Exercise
4
Depression or Rapid Mood Swings
5
Dark Circles Under the Eyes
6
Dizziness
7
Lack of Mental Alertness
8
Catch Colds Easily When Weather Changes
9
Difficulty Breathing
10
Water Retention
11
Eyes Sensitive to Bright Lights
12
Feel Weak and Shaky
13
Muscle Weakness
14
Pain in Back of the Head and Neck When Getting Up in the Morning
15
Dizzines/Vertigo
16
Excessive Thirst
17
Chronic Fatigue/Hyperactivity
18
Puffiness in Face and Body
19
Excessive Salt/Sugar Craving
20
Hypoglycemia
21
Phobias/Recurrent Activity
22
Headaches
23
Kidney Problems
24
Is your Blood Pressure High/Low
25
Allergies/Asthma
26
Use Oral Cortisone/Prednisone
27
Chronic Drug/Alcohol Abuse
28
Osteoporosis

Section B:

1
Shortness of Breath on Exertion
2
Chest Pain While Walking
3
Calf Muscles Cramp While Walking
4
Heart Pounds Easily/Palpitations
5
Heart Skip Beats or Has Extra Beats
6
Swelling of Feet and Ankles
7
Rapid Beating Heart
8
Heartburn After Eating
9
Pain in Left Arm
10
Exhaustion with Minor Exertion
11
At Rest... Heart Beats per Minute
12
Don't Do Aerobic Exercises
13
Don't Exercise Regularly
14
Bright Red Nose
15
Use of Heart Medication/Pacemaker

Section C:

1
Cold Hands and Feet
2
Varicose Veins
3
Calf Muscles Cramp When Walking
4
Headaches (Throbbing)
5
Numbness/Blue Color of Extremities
6
Poor Concentration
7
Ringing in Ears
8
Frequent Nose Bleeds
9
Heart Attack/Angina
10
Stroke
11
Vertical Wrinkle in Lower Ear Lobe
12
Blood Presurre High/Low
13
Dizziness/Easy Fatigued
14
Abnormal EKG

Part V - Male Only.

Section A:

1
Difficulty Urinating
2
A Sense of Bladder Fullness
3
Increased Straining With Smaller and Smaller Amount of Urine Passed
4
Rose Colored (Bloody Urine)
5
Pain or Burning While Urinating
6
Wake Up at Night to Urinate
7
Dripping After Urination
8
Lack of Sex Drive
9
Ejactulation Causes Pain
10
History of Prostate Infections
11
Pain in Rectum

Section B:

1
Difficulty Attaining and/or Maintaining an Erection
2
Anxiety or Fear of Sexual Intimacy
3
Premature Ejaculation
4
Pain/Coldness in Genital Area
5
Acne
6
Infertile/Low Sperm Count
7
Varicose Veins on Scrotum
8
Vasectomy

Section C:

1
Discharge
2
Past or Present Rash on Penis
3
Swollen Genitals
4
Swelling in Groin
5
Venereal Disease (Gonorrhea, Syphilis, Herpes, or Other)
6
Cancer of Sexual Organs

Part VI - Female Only.

Section A: PMS

Check if you experience any of these symptoms within approximately 2 weeks (ovulations) prior to menstruation (Section A only)

1
Monthly Weight Gain
2
Depression
3
Bloating and Swelling
4
Moodiness/Irritability
5
Nausea and/or Vomiting
6
Anxiety/Irritability
7
Leg Cramps and Tenderness
8
Craving for Sugar/Salt
9
Headaches
10
Easily Distracted/Poor Concentration
11
Anger/Hostility
12
Tender Breasts
13
Low Backache
14
Acne
15
Constipation

Section B:

1
Vaginal Itching/Dryness
2
Vaginal Discharge/Infection
3
Low or No Desire for Sex
4
Dislike for Intercourse
5
Missed Periods
6
Over 15, and Have Not Begun Menstruation
7
Unable to get Pregnant/Infertility
8
Miscarriages/Abortion/Tubal Ligation
9
Cancer of Reproductive Organs
10
Pelvic Inflammatory Disease (PID)

Section C:

Check if you experience any of these symptoms during menstruation.

1
Low Abdominal Pain
2
Dull Ache Radiating to Low Back or Legs
3
Increased Urinary Frequency
4
Pelvic Soreness
5
Diarrhea
6
Headaches
7
Abdominal Bloating
8
Menstrual Pain/Endometriosis
9
Nausea and/or Vomiting
10
Have to Lie Down on First or Second Days of Period
11
Craving for Sweets
12
Insomnia
13
Light Scanty Blood Flow
14
Pain and Cramps Without Blood Flow
15
Heavy Menstrual Cycle
16
Anxiety About Menstrual Cycle
17
Pain During Period/Progressively Getting Worse With Time

Section D:

1
Vaginal Bumps and Sores
2
Pubic Sore Area
3
Pain in Ovaries
4
Breasts Painful/Fibrocystic Breasts
5
Water Retention/Swollen Feeling
6
Mother Used D.E.S. While Pregnant
7
Recent PAP Smear Positive
8
Family History of Breast Cancer
9
Birth Control Pills/IUD
10
Personal History of Breast Cancer
11
Ovarian Cyst
12
Uterine Cysts
13
Breast Lumps/Discharge

Section E:

1
Hot Flashes
2
Night Sweats
3
Depression/Mood Swings
4
Insomnia
5
Heavy Bleeding Two Weeks/Month
6
Sweating Throughout the Day
7
Dryness of Skin, Hair and Vagina
8
Painful Intercourse
9
Vaginal Pain/Itching
10
Use Estrogen/Progesterone
11
Osteoporosis
12
Hysterectomy

Part VII

Section A:

1
Pain in Fingers
2
Bones Sore/Painful
3
Cavities
4
Arthritis
5
Drink Carbonated Beverages/Soda
6
Gun Disease (Trigger Finger)
7
Bone Loss
8
Calcium Deposits
9
Use Antacids
10
Dentures
11
Bone Deformity
12
Osteroporosis/Osteomalacia
13
Recent Bone Fracture
14
Are you Post Menopausal
15
History of Calcium Deficiency

Section B:

1
Muscle Spasms/Tetany
2
Tightness in Shoulder Muscles
3
Muscle Cramps
4
Pain in Arms and Hands
5
Leg Cramps at Night
6
Stiff All Over
7
Stiff in the Morning
8
Unable to Sit Straight
9
Pain in Neck and/or Shoulders
10
Pain or Popping in Jaw

Section C:

1
Over Flexible Joints (Double-Jointed)
2
Back Pain/Bone Pain
3
Swollen Knees/Elbows
4
Athletic Injury
5
Bursitis
6
Tendonitis
7
Joint Pain
8
Vertebral Subluxation (Out of Adjustment)
9
Herniated Disc
10
Loss in Height
11
Injure Easily
12
Connective Tissue Disease

Part VIII

Section A:

1
Dizziness When Standing Suddenly
2
Loss of Vision When Standing Suddenly
3
Crave Sweets/Alcohol
4
Headaches Relieved by Eating Sweets
5
Feel Shaky
6
Irritable if a Meal is Missed
7
Wake Up in the Middle of the Night Craving Sweets
8
Feel tired or Weak if a Meal is Missed
9
Heart Palpitations/Cold Sweats
10
Need to Drink Coffee to Get Started
11
Impatient, Moody, Nervous
12
Feel Tired 1 to 3 Hours After Eating
13
Poor Memory/Concentration
14
Hypoglycemia by Glucose Tolerance Test
15
Calmer After Eating

Section B:

1
Night Sweats
2
Increased Thirst/Appetite
3
Lowered Resistance to Infection
4
Fatigue
5
Boils and Leg Sores
6
Overweight
7
Muscle Weakness
8
Crave Sweets, Eating Sweets Does Not Relieve Symptoms

Section C:

1
Frequent Indigestion
2
Fullness in the Abdomen
3
Chronic Digestive Disturbances
4
Foul Smelling Stools
5
Chronic Diarrhea
6
Chronic Alcohol Abuse
7
Pancreatic Disease
8
Use of Pancreatic Enzymes
9
Weight Loss (Sudden)
10
Severe Abdominal Pain Radiating to Back

Part IX

Section A:

1
Burping
2
Fullness for Extended Time After Meals
3
Bloating
4
Poor Appetite
5
Stomach Upsets Easily
6
History of Constipation
7
Known Food Allergies
8
Excessive Gas
9
Indigestion
10
Regurgitation of Food Eaten

Section B:

1
Abdominal Cramps
2
Indigestion 1-3hrs. After Eating
3
Fatigue After Eating
4
Lower Bowel Gas
5
Alternating Constipation and Diarrhea
6
Diarrhea (Chronic)
7
Roughage and Fiber Caues Constipation
8
Mucus in Stools
9
Stools Poorly Formed
10
Shiny Stool
11
3 or More Large Bowel Movements Daily
12
Foul Smelling Stool
13
Dry Flaky Skin and/or Dry Brittle Hair
14
Pain in Left Side, Under Rib Cage
15
Acne
16
Food Allergies/Sensitivities

Section C:

1
Stomach Pains/Heartburn
2
Stomach Pains Just Before and/or After Meals
3
Dependency of Antacids
4
Chronic Abdominal Pain
5
Butterfly Sensations in Stomach
6
Difficulty Belching
7
Stomach When Emotional Upset
8
Chronic Bad Breath
9
Sudden, Acute Indigestion
10
Relief of Symptoms by Carbonated Drinks
11
Relief of Stomach Pain by Drinking Cream Milk
12
History of Ulcer or Gastritis
13
Current Ulcer or Gastritis
14
Black Stool When Not Taking Iron Supp.
15
Regurgitation or Hiatal-Hernia

Section D:

1
Seasonal Diarrhea
2
Frequent/Recurrent Infections (Colds)
3
Bladder and Kidney Infections
4
Vaginal Yeast Infections
5
Abdominal Cramps
6
Toe and Fingernail Fungus (White Growth)
7
Alternating Diarrhea/Constipation
8
Constipation/Hemorrhoids
9
History of Frequent Antibiotic Use
10
Eat Red Meat, Pork, Lam
11
Rapidly Failing Vision
12
History of Colon Cancer
13
Colitis/Irritable Bowel
14
Diverticulitis
15
Diverticulosis

Section E:

1
Excessive Stomach Acid
2
Chronic Diarrhea/Constipation
3
Heartburn
4
Lack of Appetite
5
Easy Bruising
6
Recurrent Depression
7
Chronic Fatigue
8
Dizziness
9
Duodenal or Peptic Ulcer
10
History of Kidney Stones
11
History of Hiatal-Hernia
12
Food Allergies

Part X

Section A:

1
Intolerance to Fried Foods
2
Headaches After Eating
3
Light Colored Stool
4
Easily Bruise
5
Constipation
6
Hard Stools
7
Sour Tase in Mouth/Bad Breath
8
Grey Colored Skin
9
Yellow in Whites of Eyes
10
Acne/Skin Eruptions
11
Body Odor
12
Fatigue and Sleepiness After Eating
13
Pain in Right Side Under Rib Cage
14
Painful to Pass Stool
15
Retain Water (Bloating)
16
Big Toe Painful or Gout
17
Dry Skin or Hair/Skin Eruptions
18
Alcoholism/Chronic Drug Abuse
19
Red Blood in Stool
20
History of Jaundice or Hepatitis
21
High Cholesterol and Low HDL
22
Cholesterol Level is Above 200
23
Cholesterol Level is Above 300
24
Triglyceride Level is Above 150

Section B:

1
Chronic Fatigue
2
Toxic Feelings
3
Left Upper Abdominal Pain
4
Removal of Spleen
5
History of Mononucleousis
6
History of Hodgkin's Disease
7
Recurrent/Chronic Anemia
8
Blood Disorders
9
Enlarged Spleen
10
Chronic Swollen Lymphnodes
11
Bleeding Disorders
12
Leukemia/Lymphoma

Part XI

Section A:

1
Inflamed or Bleeding Gums
2
Running Nose
3
Gets Boils/Styes/Cysts
4
Frequent Throat Infections
5
Cold Sores, Fever Blisters
6
Poor or Slow Wound Healing
7
Hives/Rashes
8
Swollen Lymph Glands Ear Infections
9
Acne
10
Slow to Recover From Colds or Flu
11
Catch Colds or Flu Easily
12
Muscle Aches
13
Swollen Joints/Joint Pain
14
Food Sensitivity or Allergy
15
Certain Foods Make You Sick, Depressed, Jittery
16
Chronic Pain
17
Mucus in Throat
18
Post Nasal Drip
19
Discharge From Eyes or Redness
20
Eyes Itch/Puffiness
21
Ear Discharge or Ears Stuffed Up
22
Breath Through Mouth
23
History of Mono
24
Recurrent Tonsillitis
25
Chronic Lung Congestion/Cough
26
Candida/Yeast
27
Recurrent Parasite Infection
28
Sexually Transmitted Disease
29
Eczema or Psoriasis
30
Asthma/Bronchitis
31
Migraine Headaches
32
History of Cancer/Chemotherapy
33
Colitis (Present or Past)
34
Recurrent Kidney/Bladder Infections
35
Rheumatoid Arthritis/Autoimmune Disorder
36
Silicon Breast Implants
37
Use Cortisone/Prednisone
38
Allergies
39
Sinusitis/Rhinitis/Hay Fever