questionnaire

The World Health Organisation recognises Acupuncture as an effective treatment for over 100 medical conditions. Acupuncture therapy is one of the safest, most effective and cost-efficient methods of health care. Acupuncture therapy has no side effects; is completely drug free and is covered by many insurance companies and employee benefit programmes.

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QUESTIONNAIRE

The Wiltshire
Acupuncture
practice

A Questionnaire helping you discover your health
Western attitudes to diet and eating tend to assume we are all the same. General dietary advice is frequently given on television, radio, in our newspapers and magazines. We are all advised to eat less fat, consume more vegetables or take additional vitamins. Fried foods are bad, steamed are good. Eggs contain too much cholesterol and we should choose low fat yoghurts, cheese and milk. Whereas this advice might help at one level it does not take into account that we all need different foods depending on our condition and the environment in which we live and work.

We often get into habits of eating what we think will be good for our bodies and health, and not what our bodies actually need.

A Traditional Chinese Medicine (TCM) diagnosis will be prepared from the information you supply in this health assessment questionnaire.

We will send you this together with corrective nutritional advice based on that diagnosis. The advice will be specifically for you derived from the information you supply in this questionnaire and should not be recommended to anyone else.

The Oriental approach, recognises that everyone has different nutritional and dietary needs based on their constitution. Over 2000 years of careful observation has lead to a method whereby an assessment of an individual's health can be made from understanding patterns and indicators from questioning. Acupuncture and Herbalism are based on the same principles of Traditional Chinese Medicine. A diagnosis can be derived from the answers to the following questions, and dietary advice given that will address your individual problems and restore and maintain your health.

Please read all the questions before completing this questionnaire. This will help ensure that you fill it in correctly.

Some of the questions are gender and age specific and will not relate to you. In these cases just leave them blank.

The questions relate to your condition in the last 3 months only and it is very important when thinking about the answers that you bear this in mind.

naturally healthy NUTRITIONAL ADVICE FOR BETTER HEALTH

Questionnaire
There follows 166 questions in 9 different sections. All require a simple 'YES' or 'NO' answer.Follow the instruction carefully for each section. When you have completed all relevant sections print out this page - good luck. You could save this page and fill it in off line. All cost details are on the payment page. Click here to see a sample response page

Complete this section to let us know if you have any of the symptoms listed on a regular or persistent basis. Your combined answers will allow us to diagnose your general health, strengths and weaknesses. Put a tick in as many boxes as appropriate. There will be an opportunity to answer more fully the nature of your problem(s), discomfort(s) or concern(s) later in the questionnaire. GENERAL NOTE TO ALL QUESTIONS You should only answer 'YES' if the condition asked about is regular. i.e. 1.1 Shortness of breath. If this happened once in the last 3 months do not put a tick in the 'Yes' box, however if this is something that is happening often put a tick in the 'Yes' box for this question.

YOUR INFORMATION

Email

First Name

Last Name

Title (optional)

Male Female

Address

City

State/Province

Zip/Postal Code

Phone Number

Fax (optional)

SECTION 1 -General
Complete this section to let us know if you have any of the symptoms listed on a regular or persistent basis. Your combined answers will allow us to diagnose your general health, strengths and weaknesses. Put a tick in as many boxes as appropriate. There will be an opportunity to answer more fully the nature of your problem(s), discomfort(s) or concern(s) later in the questionnaire. GENERAL NOTE TO ALL QUESTIONS You should only answer 'YES' if the condition asked about is regular. i.e. 1.1 Shortness of breath. If this happened once in the last 3 months do not put a tick in the 'Yes' box, however if this is something that is happening often put a tick in the 'Yes' box for this question.
If you can't definitely place a cross in either the 'YES' or 'NO' boxes for each question leave blank.
In the last 3 months have you experienced ...

1.1 Shortness of breath ?
NO YES

1.2 Little desire to speak or move ?
NO YES

1.3 Out of the ordinary day time sweat ?
NO YES

1.4 Loss of appetite ?
NO YES

1.5 Poor appetite ?
NO YES

1.6 Sores in mouth?
NO YES

1.7 Dry mouth ?
NO YES

1.8 Dry lips ?
NO YES

1.9 No thirst ?
NO YES

1.10 Preference for warm drinks ?
NO YES

1.11 Aversion to cold ?
NO YES

1.12 Cold limbs ?
NO YES

1.13 Diarrhoea?
NO YES

1.14 Copious clear urine?
NO YES

1.15 Swollen ankles?
NO YES

1.16 Numb limbs ?
NO YES

1.17 Spots in visual field ?
NO YES

1.18 Dizziness ?
NO YES

1.19 Dry skin?
NO YES

1.20 Dry hair?
NO YES

1.21 Palpitations?
NO YES

1.22 Insomnia?
NO YES

1.23 Constipation?
NO YES

1.24 Forgetfulness?
NO YES

1.25 Strong thirst?
NO YES

1.26 Aversion to heat ?
NO YES

1.27 Dark scanty urine ?
NO YES

1.28 Night sweats?
NO YES

1.29 Sore throats and low grade fever?
NO YES

1.30 Restlessness?
NO YES

1.31 Weight loss ?
NO YES

1.32 Digestive problems?
NO YES

1.33 Bloating?
NO YES

1.34 Wind?
NO YES

1.35 Abdominal pains ?
NO YES

1.36 Food allergies?
NO YES

1.37 Tiredness ?
NO YES

1.38 Tension?
NO YES

1.39 Anger ?
NO YES

1.40 Menstrual irregularities.
This question only has relevance
if you are under 45. If you are
over this do not answer questions
- 1.41 & 1.43.

1.41 Scanty or absent menses/ period ?
NO YES

1.42 Distension or lumps in the breasts?
NO YES

1.43 Painful periods ?
NO YES

1.44 Headaches?
NO YES

1.45 Red eyes?
NO YES

1.46 Eye problems ?
NO YES

1.47 Ringing in ears?
NO YES

1.48 Spasm and shaking in muscles?
NO YES

1.49 Coughing?
NO YES

1.50 Breathing difficulties?
NO YES

1.51 Skin problems?
NO YES

1.52 Nasal congestion ?
NO YES

1.53 Low back pain ?
NO YES

1.54 Pain in knees ?
NO YES

1.55 Urinary difficulties?
NO YES

1.56 Afternoon sweats ?
NO YES

SECTION 2 - Sleep
Sound sleep is an important factor in general health. Complete this section to let us know of any particular sleeping problems you may have. Remember you should only answer 'YES' if the condition asked about is regular i.e. Question 2.1 Difficulty in falling asleep? A 'YES' would only be appropriate if this happens more often than not.

Remember if you can't definitely place a cross in either the 'YES' or 'NO' boxes for each question leave blank.
In the last 3 months have you experienced ...

2.1 Difficulty in falling asleep?
NO YES

2.2 Waking up in the night?
NO YES

2.3 Sleep disturbed by dreaming?
NO YES

2.4 Waking earlier than you would
like and are unable to return to
sleep? (Only answer this question
if you are 50 or under).
NO YES

2.5 Feel tired after eating?
NO YES

2.6 Your mind racing when you are
trying to go to sleep?
NO YES

2.7 If 'YES' to question 2.2, is there one specific window of time you wake up in? Only tick one box. If you don't fit to the windows time do not apply or you wake up regularly ignore his question.

11pm-1am
NO YES

1am-3am
NO YES

3am-5am
NO YES

5am-7am
NO YES

7am-9am
NO YES

SECTION 3 Headaches and dizziness
For section 3 and section 4 you should only answer 'YES' if the condition asked about is regular. Only describe a headache if it is a repeating pattern in the last 3 months.

3.1 Are the headaches very recent
in onset? Only answer 'Yes' to
this question if they have started
in the last 10 days.
NO YES

3.2 Do the headaches come on slowly?
NO YES

3.3 Are the headaches in the
daytime only?
NO YES

3.4 Are the headaches in the
evening only?
NO YES

3.5 Are the headaches located principally in any of the following areas?
You can place a tick in more than one 'YES' box if necessary.

a. Nape of neck?
NO YES

b. Forehead?
NO YES

c. Temples and side of head?
NO YES

d. Vertex (top of head)?
NO YES

e. All of head?
NO YES

f. None of above.?
NO YES

The next questions, 3.6 to 3.9, are about the sensation of the headaches. You can put a tick in more than one box if you feel this best describes the sensation or if none of the descriptions match the sensation you feel leave blank.

3.6 Is the pain principally like a
heavy feeling?
NO YES

3.8 Is the pain distended and throbbing?
NO YES

3.9 Is the pain boring like a nail
on a small point?
NO YES

3.10 Is the pain made worse by exposure to:
a. Heat? NO YES
b. Cold? NO YES

3.11 Is the headache made worse
by tiredness or improved by rest?
NO YES

3.12 Do you suffer from severe dizziness?
NO YES

3.13 Do you suffer from slight
dizziness with a sensation of muzziness?
NO YES

3.14 Do you suffer from slight dizziness
which is worse when tired?
NO YES

SECTION 4 - Ears and Eyes
In the last 3 months have you experienced ...

4.1 Do you ever get a whistling,
hissing or other noise in the ear(s)?
NO YES
If your answer is NO go to
question 4.6.

4.2 Is the noise made worse by
pressing on the ear(s)?
NO YES

4.3 Is the noise made better by
pressing on the ear(s)?
NO YES

4.4 Is the pitch of the noise high,
like a whistling sound?
NO YES

4.5 Is the sound of the noise low,
like rushing water?
NO YES

4.6 Have you experienced any sudden
onset of deafness?
NO YES

4.7 Have you experienced a slow
onset of deafness? Remember this
question and Q 4.7 only applies
to the last 3 months.
NO YES

4.8 Do you experience pain in your
eye(s), this would include redness
and swelling?
NO YES

4.9 Do you experience a sensation
of pressure in the eye(s)?
NO YES

4.10 Do you experience dryness in
the eye(s)?
NO YES

SECTION 5 - Specific Pain in your body
It is important that the body is pain free for good health. Complete this section to let us know about your pain (OTHER THAN HEADACHES AND PAIN IN THE EYES AND EARS) It is important if you have more than one area of pain to only describe the WORST of these. Remember only tick the YES box if the condition is regular and happens more often than not. Otherwise tick the NO box.
In the last 3 months have you experienced ...

5.1 Are you experiencing pain in
any part of your body?
NO YES

5.2 Is the pain made better by
pressure?
NO YES

5.3 Is the pain made worse by
pressure?
NO YES

5.4 Is the pain made better by
eating?
NO YES

5.5 Is the pain made worse by
eating?
NO YES

5.6 Is the pain dull and nagging?
NO YES

5.7 Is the pain sharp?
NO YES

5.8 Is the pain slow in onset?
NO YES

5.9 Is the pain sudden in onset?
NO YES

5.10 Is the pain better with rest?
NO YES

5.11 Is the pain better for movement?
NO YES

5.12 Is the pain better for lying down?
NO YES

5.13 Is the pain better for sitting?
NO YES

5.14 Is the pain better for heat?
NO YES

5.15 Is the pain better for cold?
NO YES

SECTION 6 - General pain and sweating in/on your body
In the last 3 months have you experienced…

6.1 Pain all over with a sensation
of tiredness?
NO YES

6. 2 Pain in all muscles with a hot
sensation on the skin?
NO YES

6.3 Pain in your joints that moves
from joint to joint?
NO YES

6.4 Pain in your joints that is
fixed and painful? Read the next
question before answering this.
NO YES

6.5 Pain in your joints that is
fixed and painful with numbness
and swelling?
NO YES

6.6 Back ache that is continuous
and dull?
NO YES

6.7 Back ache that is made worse
during cold periods?
NO YES

6.8 Back ache that is like a boring
pain? NO YES

6.9 Pain in your neck and shoulders?
NO YES

6.10 Numbness in the arms/legs/
hands or feet on both sides?
NO YES

6.11 Pain in your chest?
NO YES

6.12 Pain in your chest accompanied
by coughing and yellow sputum?
NO YES

6.13 Feeling of distension and
stiffness at the bottom of
the rib cage?
NO YES

6.14 Pain in the stomach that is dull
and not severe?
NO YES

6.15 Pain in the stomach that
is severe?
NO YES

6.16 Is the stomach pain made better
by eating?
NO YES

6.17 Is the stomach pain made
worse by eating?
NO YES

6.18 Pain in your lower abdomen?
NO YES

6.19 Is the pain in the lower
abdomen made better by bowel
movement?
NO YES

6.20 Is the pain in the lower
abdomen made worse by bowel
movement?
NO YES

The following questions are about unusual sweating on the body and again only answer ‘YES’ if the condition asked about happens more often than not and only if the condition happens in the absence of heavy exercise (in which case you would be expected to sweat.)Have you experienced any of the following:SECTION 6 - General pain and sweating in/on your body
In the last 3 months have you experienced…

6.21 Unusual sweating only on
the head?
NO YES

6.22 Oily sweat on the forehead?
NO YES

6.23 Sweat on the legs and arms
only?
NO YES

6.24 Sweat on the hands only?
NO YES

6.25 Sweat over the whole of
the body?
NO YES

6.26 Sweat on the palms, soles
and chest?
NO YES

6.27 Unusual sweat at night time?
NO YES

6.28 Unusual sweat during the day?
NO YES

SECTION 7 - Bowels and Bladder
In the last 3 months have you experienced…

7.1 Acute constipation?
NO YES

7.2 Constipation with small bitty
stools?
NO YES

7.3 Constipation with abdominal
pains?
NO YES

7.4 Do you alternate between
constipation and diarrhoea?
NO YES

7.5 Pain with diarrhoea?
NO YES

7.6 Chronic diarrhoea?
NO YES

7.7 Diarrhoea in the morning
every day? }
NO YES

7.8 Loose stools with undigested
food?
NO YES

7.9 Black or dark stools?
NO YES

7.10 Difficulty in urination?
NO YES

7.11 Frequent and copious urination?
NO YES

7.12 Frequent and scanty urination?
NO YES

7.13 Pain before urination?
NO YES

7.14 Pain during urination?
NO YES

7.15 Pain after urination?
NO YES

7.16 Pale urine?
NO YES

7.17 Urine that is dark in colour?
NO YES

7.18 Urine that is cloudy ?
NO YES

SECTION 8 Menstruation
It is only relevant to answer this section if you are a woman of 45 or under .
Have you experienced any of the following: i.e. in the last 3 months have you had ...

8.1 Are your menstrual cycles Irregular?
NO YES

8.2 Your period early?
NO YES

8.3 Your period late?
NO YES

8.3 Your period late?
NO YES

8.4 Very heavy periods
NO YES

8.5 Scanty periods?
NO YES

8.6 Pain before your period?
NO YES

8.7 Pain during your period?
NO YES

8.8 Pain after your period?
NO YES

SECTION 9 Thirst and drink
Have you experienced any of the following: i.e. in the last 3 months have you had ...

9.1 Desire to drink large amounts of cold liquids?
NO YES

9.2 No desire to drink?
NO YES

9.3 Thirst but with no desire to drink?
NO YES

9.4 Thirst with a desire to sip liquids slowly?
NO YES

9.5 Desire to drink warm liquids?
NO YES

As yet we only accept cheques so you will need to print this page(s) and send in the post together with a cheque

Once you have printed the questionnaire click on the payment below.
Do not leave this page before printing it out. The information entered here may be lost once you leave this page

All cost details are on the payment page. Click here to see a sample response page

This questionnaire is intended for those that want to improve their health and the advice given is not intended for treatment of major problems. We would strongly advise anyone with major concerns or medical problems to consult their doctor or medical adviser without delay. We can not accept responsibility for any worsening health condition after following the dietary advice that we give.

Contact us
info@naturallyhealthy.net

The Wiltshire
Acupuncture
practice,
Telephone +44 (0)1672 539582