Do you suffer from Bell's Palsy (facial muscle droop - one-sided facial paralysis)?
No / don't know
Mildly
Moderately
Seriously
Severely
231.
Have you suffered injury to your spinal cord?
No / don't know
Mild
Moderate
Serious, including temporary loss of motor control
Severe, including permanent paralysis
232.
Do you ever injure yourself without noticing (feeling) it? An example would be cutting yourself with a knife and only finding out when someone points out the blood.
Don't know
No - I always feel injuries
Occasionally
Frequently
233.
Anywhere on your body, do you have any abnormal skin sensations or lack of sensation? This includes reduction in the sense of touch, pain, burning, tingling, pins and needles, vibrations, numbness, etc.
Don't know
No
Yes More questions later...
Add any additional information here for the questions above:
Please mention the question number(s) if possible.
Add any additional information here for the questions above:
Please mention the question number(s) if possible.
SYMPTOMS: GASTRO-INTESTINAL: GENERAL
239.
Does your anus itch?
Never / don't know
Occasionally
Often, mostly at night
Often
240.
Do you suffer from belching (burping) within 1 hour of a meal?
Don't know
No
Occasionally
Often
241.
Do you suffer from bloating or digestive disturbances after eating?
Don't know
No
Occasionally
Often
242.
Do you feel as though food remains in your stomach too long? The stomach usually retains food for 3-4 hours before releasing it to the small intestine.
Have you had a portion of your small bowel removed? This procedure is known as a small bowel resection.
No
Don't know
Less than 50cm (20 inches)
More than 50cm (20 inches)
245.
Do you experience pain with swallowing?
No / don't know
Occasionally / mild
Often / severe
246.
Do you have difficulty swallowing? In other words, do you have difficulty getting liquids or chewed food to "go down"?
No / don't know
Occasionally / mild
Often / severe
247.
Do you suffer from excess lower bowel gas (flatulence)?
No / 'average' / don't know
Moderately
Severely
248.
How often do you suffer from vomiting that is not part of a known condition such as food poisoning or indigestion?
Don't know
Never / very rarely
Occasionally - a few times per year
Regularly - a few times per month
Often - several times per week
249.
How often do you suffer from nausea that is not due to a known cause such as pregnancy or hunger?
Don't know
Never / very rarely
Occasionally - a few times per year
Regularly - a few times per month
Often - several times per week
250.
Is your stomach upset by taking supplement tablets?
No / don't know
Yes
251.
Have you experienced any form of abdominal pain, discomfort or bloating within the past 3 months? This includes upper abdominal pain such as experienced in heartburn or ulcers.
Don't know
No
Yes, but fully resolved now
Yes More questions later...
Add any additional information here for the questions above:
Please mention the question number(s) if possible.
SYMPTOMS: GASTRO-INTESTINAL: CONDITIONS
This section asks specifically about conditions that you are already aware of. If you are unsure of an answer, leave it as "don't know" - you will be asked about individual symptoms elsewhere.
Other than black/tarry, pale or blood-colored stools, do you regularly have stools of any other unusual color? Do not include color that results from obvious causes such as drugs, food colorings or foods such as beetroot.
Don't know
No
Yes, green
Yes, orange
Yes, other color (please make note below)
276.
How offensive do your stools usually smell? This is difficult to quantify, but a strong smell despite brief exposure to the air, or comments by others, are good indicators!
Don't know
Never / rarely offensive
Occasionally offensive
Often offensive
Always offensive
277.
Do you have frequent intestinal pain or cramping with an urge to defecate, sometimes without success?
No / don't know
Rarely
Occasionally
Approximately daily
Several times per day
278.
Have you noticed undigested fat in your stools?
No / don't know
Occasionally
Often
279.
Have you noticed undigested food in your stools, other than corn?
No / don't know
Occasionally
Often
Add any additional information here for the questions above:
Please mention the question number(s) if possible.
SYMPTOMS: MOUTH/ORAL
280.
Do you have bad breath?
No / don't know
Occasionally, minor
Often minor or occasionally moderate
Often moderate or occasionally very bad
Often very bad
281.
Do you have any kind of bad or abnormal taste in your mouth?
No / rarely / don't know
Yes, some
Yes, significant
282.
Do you have a bitter taste in your mouth, particularly after meals?
Other than ulcers, do you have any tenderness or soreness inside your mouth?
No / don't know
Yes, some
Yes, significant
288.
Do you have a rough, raw or sore sensation in the back of your mouth or throat?
No / don't know
No
Not currently, but happens frequently
Yes, somewhat sore
Yes, very sore
289.
In general, how plentiful is the saliva in your mouth?
My mouth is often very dry
My mouth is sometimes a bit dry
Normal / don't know
I always have plenty of saliva
Excess saliva, with a tendency to drool
290.
Are your teeth sensitive or tender?
No / don't know
Somewhat
Very
291.
How often do you use dental floss to clean your teeth?
Don't know
Never / rarely
Occasionally
Several times per week
Daily or more frequently
292.
Do you suffer from clenching or grinding of teeth while you sleep (Bruxism)? If you sleep with a partner, it may be worth asking them.
No / don't know
Mildly
Moderately
Seriously - some damage to teeth
Severely - extensive damage to teeth
293.
Are any of your teeth noticeably loose? A very small amount of tooth movement is normal. Only mention movement that seems to be more than it used to be or which is accompanied by pain. Do not include teeth that are loose due to past trauma/injury.
Don't know
No
Yes, one
2-4
More than 4 teeth
294.
How often do you get dental cavities?
Not applicable / don't know
I have none at all - perfect teeth
None in the past 5 years
1 or 2 in the past 5 years
3 or more in the past 5 years
295.
Other than dental cavities, are there any white chalky spots or brown stains and pitting on your teeth?
Don't know
No, definitely not
Yes, on some teeth
Yes, on most teeth
296.
How many mercury amalgam ("silver") fillings do you currently have in your teeth?
Don't know
None
1 to 3, all in good condition
4 to 7 in good condition, or 1 to 3 in poor
8 or more in good condition, or several in poor
297.
Have you had any mercury amalgam fillings removed?
No / don't know
1 to 3
4 to 6
7 to 10
More than 10
298.
If you have had mercury amalgam fillings removed, were they removed using special procedures to protect you from additional mercury exposure?
Not applicable / don't know
All amalgams still present
Yes, all removals used protective measures
Some of the removals were done with precautions
No special precautions were taken
299.
Do your gums bleed easily?
No / don't know
Somewhat
Very
300.
Do your gums have dark spots or areas?
No / normal pink color / don't know
Yes, at least one
Yes, more than one, or a larger area
301.
Is your tongue sore?
No / don't know
Occasionally / a little
Often / very
302.
Is your tongue swollen or inflamed?
No / don't know
Somewhat / occasionally
Very / often
303.
Do you have a coated tongue? Looking at your tongue in the mirror, is there more than a slight whitish coating on the back-middle of your tongue?
No / don't know
Somewhat
Yes, severe
304.
Do you ever cough up small, soft, solid lumps of material ("curds")? If so, please note the color.
Don't know
No
Yes, white or almost white
Yes, yellowish
Yes, some other color (please add note below)
305.
In general, how soft or strong is your voice?
Very soft/weak
Softer/weaker than average
Average / don't know / I am mute
Louder/stronger than average
Very loud/strong
306.
Speech. Which word / phrase best describes the way you speak?
Slowly
Incoherently - people often don't understand me
Averagely - accurately / don't know
Rapidly
307.
Has your voice changed in any way, for no apparent reason?
No / don't know
Mildly
Moderately
Yes, a lot
Yes, almost beyond recognition
308.
Speaking ability. Has it become more difficult for you to speak over time?
No / don't know
Minor decline occurring over more than 1 year
Severe decline occurring over more than 1 year
Minor decline within the past year
Severe decline within the past year
309.
Has your voice become hoarse (rough or grating in sound)?
No / don't know
Yes, for less than one week
Yes, for less than one month
Yes, for less than one year
Yes, for more than one year
Add any additional information here for the questions above:
Please mention the question number(s) if possible.
GLOSSARY
Abdomen (Abdominal) That part of the body between the chest and the hips that contains the stomach, intestines, liver, bladder, pancreas and other organs.
Abdominal Hernia An abdominal hernia occurs when there is an area where the muscles are weak, and this allows the internal organs to bulge through the abdominal wall. Signs include a lump (soft bulge of tissue) or a small, localized swelling on the abdomen.
Atrophic Gastritis Chronic inflammation of the stomach that causes the breakdown of the mucous membranes and a reduction in the number of functioning stomach cells. Seen mainly in the elderly.
Bell's Palsy One-sided facial paralysis of sudden onset and unknown cause. The mechanism is presumed to involve swelling of the nerve due to immune or viral disease, with ischemia and compression of the facial nerve in the narrow confines of its course through the temporal bone.
Bruxism Prolonged, unintentional grinding and clenching of the teeth, usually occurring during sleep. 'Bruxers' are often unaware that they have developed this habit. Symptoms include abraded/chipped teeth (in extreme cases, waking up with tooth chips in the mouth); facial pain; oversensitive teeth; tense facial and jaw muscles; headaches; dislocation of the jaw; damage to the tooth enamel, exposing the inside of the tooth; a popping or clicking in the temporomandibular joint (TMJ); tongue indentations; damage to the inside of the cheek.
Canker Sores (Aphthous Ulcers, Apthous Stomatitis) Small, painful ulcers that occur on the inside of the cheek, lip or underside of the tongue. Caused by an assortment of viruses, doctors call this condition aphthous stomatitis. Canker sores usually clear up by themselves within a week or so, but they often recur, sometimes in the form of multiple sores.
Chapped Roughened, reddened, or cracked skin, especially as a result of cold or exposure.
Cirrhosis (Liver Cirrhosis) A long-term disease in which the liver becomes covered with fiber-like tissue. This causes the liver tissue to break down and become filled with fat. All functions of the liver then decrease, including the production of glucose, processing drugs and alcohol, and vitamin absorption. Stomach and bowel function, and the making of hormones are also affected.
Cold Sore (Cold Sores, Fever Blister, Fever Blisters) Localized collections of clear fluid causing elevation of the skin, separating it into an upper and lower layer, often recurring about once per year. Generally due to Herpes Type 1 (HSV1) and appearing as blisters on the outside surface of the lips but also on the face and inside the mouth, eventually breaking down to form small ulcers and finally scabs.
Colon (Colonic) The part of the large intestine that extends to the rectum. The colon takes the contents of the small intestine, moving them to the rectum by contracting.
Constipation (Constipated) Difficult, incomplete, or infrequent evacuation of dry, hardened feces from the bowels.
Crohn's Disease (Crohn's) Chronic inflammatory disease of the gastrointestinal tract. The most common symptoms are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Bleeding may be serious and persistent, leading to anemia.
Dental Floss A thin, nylon string, waxed or unwaxed, that is inserted between the teeth to remove food and plaque.
Diarrhea Excessive discharge of contents of bowel.
Diverticular Disease (Diverticulitis, Diverticulosis) Some people develop small pouches (diverticula) that bulge outward through weak spots in the colon. Diverticulosis is the condition of having these pouches; diverticulitis is an inflammation or infection in these pouches. The conditions diverticulosis and diverticulitis are both referred to as diverticular disease. Diverticulosis may not cause any symptoms but could include mild cramps, bloating and constipation - all of which are common to other conditions such as IBS or ulcers. The most common symptoms of diverticulitis are abdominal pain and tenderness around the left side of the lower abdomen. When infection is the cause, fever, nausea, vomiting, chills, cramping and constipation may also occur.
Dysentery An inflammatory disorder of the lower intestinal tract, usually caused by a bacterial, parasitic, or protozoan infection and resulting in pain, fever, and severe diarrhea, often accompanied by the passage of blood and mucus.
Flatulence Abnormal amount of gas in the stomach and intestines.
Gallbladder (Gall Bladder) A small, digestive organ positioned under the liver, which concentrates and stores bile. Problems with the gallbladder often lead to gallbladder attacks, which usually occur after a fatty meal and at night. The following are the most common symptoms: steady, severe pain in the middle-upper abdomen or below the ribs on the right; pain in the back between the shoulder blades; pain under the right shoulder; nausea; vomiting; fever; chills; jaundice; abdominal bloating; intolerance of fatty foods; belching or gas; indigestion.
Gastric Of, relating to, or associated with the stomach.
Gastric Dumping (Gastric Dumping Syndrome) Unusually rapid transit of food through the stomach: the stomach releases its contents too quickly, resulting in adverse pH balance of the intestines.
Gastritis Inflammation of the stomach lining. White blood cells move into the wall of the stomach as a response to some type of injury; this does not mean that there is an ulcer or cancer - it is simply inflammation, either acute or chronic. Symptoms depend on how acute it is and how long it has been present. In the acute phase, there may be pain in the upper abdomen, nausea and vomiting. In the chronic phase, the pain may be dull and there may be loss of appetite with a feeling of fullness after only a few bites of food. Very often, there are no symptoms at all. If the pain is severe, there may be an ulcer as well as gastritis.
Helicobacter Pylori (Pylori) H. pylori is a bacterium that is found in the stomach which, along with acid secretion, damages stomach and duodenal tissue, causing inflammation and peptic ulcers. Although most people will never have symptoms or problems related to the infection, they may include: dull, 'gnawing' pain which may occur 2-3 hours after a meal, come and go for several days or weeks, occur in the middle of the night when the stomach is empty and be relieved by eating; loss of weight; loss of appetite; bloating; burping; nausea; vomiting.
Hemorrhoids Varicose disorder causing painful swellings at the anus; piles.
Hepatitis A This form of hepatitis is caused by an RNA virus that is transmitted person-to-person via the fecal-oral route. This may occur through water, food or close personal/sexual contact. Most children and about 50% of adults have few, if any, symptoms. Symptoms, when present, are initially flu-like, with malaise, fatigue, muscle pain and chest pain on the right side lasting 3 to 10 days. This is followed (for 1 to 3 weeks but possibly much longer) by jaundice (slight skin yellowing), anorexia, nausea, fatigue, pale stools, dark urine and liver enlargement, but usually no fever.
Hepatitis B A serious viral infection with the potential for long term consequences. It is caused by a DNA virus that has been found in virtually all body secretions and excretions. However, only blood, saliva, semen and vaginal fluids have been shown to be infectious. Transmission occurs through sexual contact, blood-to-blood contact (blood products, needle sharing, etc.), and from infected mother to infant. Virtually all affected infants and children, and many adults, receive a lesser, even symptom-free, infection. Symptoms, when present, tend to be more severe and prolonged than those for Hepatitis A: initially flu-like, with malaise, fatigue, muscle pain and chest pain on the right side. This is followed by jaundice (slight skin yellowing), anorexia, nausea, fatigue, pale stools, dark urine and tender liver enlargement, but usually no fever.
Hepatitis C Caused by an RNA flavivirus. Transmission is predominantly through broken skin on contact with infected blood or blood products, especially through needle sharing. Sexual transmission is relatively rare. Symptoms are almost always present, and very similar to those for Hepatitis B: initially flu-like, with malaise, fatigue, muscle pain and chest pain on the right side. This is followed by jaundice (slight skin yellowing), anorexia, nausea, fatigue, pale stools, dark urine and tender liver enlargement, but usually no fever.
Hiatal Hernia (Hiatal Hernias) Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (a diaphragmatic hiatus). This is a common problem and most people are not bothered by it. A hernia may allow stomach acid to flow back into the esophagus ("food pipe"), where it can cause problems. The most common symptom is burning in your chest (heartburn), especially at night when you are lying down. Other possible signs include burping and trouble swallowing.
Irritable Bowel Syndrome (IBS) A condition that causes upset intestines for a long period of time. It is very unpleasant to the sufferer but tends to be harmless and usually does not lead to more serious complaints. The symptoms vary from person to person and from day to day. In order to be diagnosed with IBS, a person must have at least three of the following symptoms: pain in the lower abdomen; bloating; constipation; diarrhea or alternating diarrhea and constipation; nausea; loss of appetite; tummy rumbling; flatulence; mucous in stools; indigestion; constant tiredness; frequent urination; low back pain; painful intercourse for women.
Laxative (Laxatives) A substance (food, herb, chemical) that stimulates evacuation of the bowels. Examples include cascara sagrada, senna, castor oil, aloe vera, bisacodyl, phenolphthalein and many others.
Liver (Hepatic) The largest and one of the most complex organs of the body, the liver is responsible for much of the metabolism of fats, proteins and carbohydrates. It is the site of much of the body's detoxification. It is connected very closely with digestion and the regulation of blood sugar, among many other functions. Found behind the ribs on the right side of
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