Follow Up Assessment - Circle Of Health Clinic printable pdf download

FOLLOW UP ASSESSMENT

Name:

Date:

Please take your time and be thorough in completing this application.

List your five major health complaints in order of importance.

RATE THEM USING THE POINT SCALE BELOW

Please circle one

0 1 2 3 4

Please rate each of the following symptoms based upon your typical health profile for the last week.

Point scale: 0 - Never or almost never have the symptom

1 - Occasionally have it, effect is not severe

2 - Occastionally have it, effect is severe

3 - Frequently have it, effect is not severe

4 - Frequently have it, effect is severe

General Symptoms

Poor Appetite

Dream disturbed sleep

Food allergies/sensitivity

Pain between shoulder blades

Heavy Appetite

Cold Hands or Feet

Crave bread or noodles

Sensitive to chemicals or fumes

Strong thirst

Poor Circulation

Poor tolerance to sugar

Chronic fatigue or fibromyalgia

Lack of thirst

Lack of interest

Crave sweets

Eat dessert or sugary snacks

Poor Sleep

Crave chocolate

Clench or grind teeth

Cuts heal slowly or scar easily

Heavy Sleep

Difficulty swallowing

Fear of impending doom

Specific foods cause bloating & fatigue

Sleepy after meals

Difficulty falling asleep

Worrier, apprehensive

Awaken after a few hours of sleep

Bitter taste in mouth

Vertigo or Dizziness

Restless leg syndrome

Difficulty focusing or general brain fog

Anxiety

Bleed Easily

Sleepy in the afternoon

Shaky or irritable if meals are delayed

Anger

Bruise Easily

Seasonal allergies

Binge or uncontrolled eating

Depression

Difficulty losing weight

Shortness of Breath

Strong light irritates eyes

Grief

Feel warm

Sweat Easily

Calm on the outside, troubled inside

Addictive nature

Feel Cold

Muscle Cramps

Difficulty gaining weight, even with

Fatigue

Night Sweats

Lack of motivation, initiative

normal appetite

Lack of strength

Bodily Heaviness

Slow starter in the morning

Peculiar taste in mouth

Nose bleeds easily

Muscle cramping,

Crave coffee or sugar in the

Describe:

or tend to bruise easily

with or with out exertion

afternoon to maintain energy

Women:

Men:

Breast tenderness

Night sweats

Painful intercourse

Prostate Problems

Vaginal dryness

Impotence

Vaginal itchiness

Premature ejaculation

Excess facial or body hair

Nocturnal Emission

Follow Up Assessment - Circle Of Health Clinic

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