For each question below, circle the number to the right
that best fits your symptoms most of the time. The score for
yeson some questions is the number inside the
parenthesis ( ).
1.twice a
week or less. 2. three to six times a week. 3. daily or several
times a day
COLON
1.Lower abdominal pain, cramping and/or spasm
1
2
3
2.Lower abdominal pain,
relief by passing stool or gas
1
2
3
3.Raw fruits, vegetables and
stress aggravate bowel pain
1
2
3
4. Diarrhoea (loose watery stools)
1
2
3
5. More than three bowel movements daily
1
2
3
6. Excessive gas or bloating
1
2
3
7. Painful, difficult, straining during bowel
movements
1
2
3
8. Hard, dry or small stools
1
2
3
9. Extremely narrow stools
1
2
3
10. Alternating diarrhea/constipation
1
2
3
11. Mucus, pus in stool
1
2
3
12 Feels bowels do not empty completely
1
2
3
13. Bright red blood following bowel movement
1
2
3
14. Anal itching
1
2
3
Please total points
LIVER/GALLBLADDER/PANCREAS
1. Moderate
to sever pain under right side of rib cage
1
2
3
2. Abdominal
pain worsens with deep breathing
1
2
3
3. Regurgitate
bitter fluid
1
2
3
4. Bloated full feeling
1
2
3
5. Belching, heart burn, gas
1
2
3
6. Fatty Foods cause indigestion
1
2
3
7. Nausea, vomiting
1
2
3
8.
Feel restless, agitated, angry
1
2
3
9. Unexplained itchy skin, worse at night
1
2
3
10.
Stool colour alternates from clay to normal brown
1
2
3
11. Feeling of poor health
1
2
3
12 Fatigue, weakness, exhaustion
1
2
3
13. Unable to concentrate, irritable confused
1
2
3
14. Swollen feet and/or legs
1
2
3
15. Easy bruising
1
2
3
16. Feeling of extreme
dryness
1
2
3
17.Reddened
skin, especially palms
1
2
3
18. Dark urine, diminished flow
1
2
3
19. Dry, flaky skin
1
2
3
20. Yellowish cast to skin
1
2
3
Please total points
HYPOTHYROID
1.Fatigue,
sluggish
1
2
3
2.Feel
cold - hands and feet
1
2
3
3.Difficult,
infrequent bowel movements
1
2
3
4. Dryness of
skin and hair
1
2
3
5. Thick,
brittle nails
1
2
3
6. Outer third
of eyebrow thins
1
2
3
7. Puffy face,
hands and feet
1
2
3
8. Swollen upper
eyelids
1
2
3
9. Eyeballs move
involuntarily
1
2
3
10.Muscles week, cramp and/or tremble
1
2
3
11. Slow mental
processes, forgetfulness
1
2
3
12 Slow heart
beats
1
2
3
13. Loss of
appetite
1
2
3
14. Abdominal
swelling
1
2
3
15. Unsteady gait movements (manner of walking)
1
2
3
16. Lack of interest in sex
1
2
3
17.Premenstrual tension
1
2
3
18. Infertility
1
2
3
19. Heavy menstrual bleeding
1
2
3
20. Gain weight easily/high cholesterol
1
2
3
21. Swelling of the neck
1
2
3
22.
Thinning hair on scalp, face and genitals
1
2
3
Please total points
It is
important to know that one may have a routine blood test for thyroid function
with results
showing normal. If symptoms are apparent it is wise to perform the "Basal
Axillary Temperature Test"
We suggest that you printout the
questionnaires and complete them. If you do not have a printer just total each
section under its heading on scrap paper.
Once you have
completed your tests we invite you to submit only the total points for each
section via the email submission below. Otherwise email to
biolmed6@bigpond.com
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initials.e.g. smithlb and date of birth ddmmyy all in lower case.
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Sex
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