Bowel movements. Have you had alternating constipation / diarrhea or recent changes in pattern?
No / don't know
Yes, some
Yes, significant
339.
Do you have black or tarry stools?
No / don't know
Yes, somewhat
Yes, very
340.
Do you have clay-colored (pale) stools?
No / don't know
Yes, somewhat
Yes, very
341.
Do you have greasy or shiny stools?
No / don't know
Yes, somewhat
Yes, very
342.
How offensively 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
343.
Do you see mucous in your stools?
Never / don't know
Occasionally
Often
344.
Do you see blood in your stools? This is red blood.
Never / don't know
Occasionally / small amount on tissue only
Occasionally / small amount on tissue and stool
Very often recently
A significant amount for some time now
345.
Do you have a tendency toward infrequent bowel movements / stools - constipation? Please answer how things would be without the use of any laxatives or supplemental fiber.
Not applicable / tend to diarrhea / don't know
No, I have at least one stool per day
Yes, stool generally less than once per day
Yes, stool every 2-3 days
Yes, stool less than every 3 days
346.
Do you have a tendency toward frequent bowel movements / stools?
Not applicable / don't know
Somewhat, have 2-3 stools per day
Yes, have 4-5 stools per day
Yes, have 6-7 stools per day
Yes, more than 8 stools per day
347.
On average, how well-formed are your bowel movements / stools? Please answer this as how things would be if you were not taking any medications, laxatives or supplemental fiber.
Don't know
Hard, difficult to pass
Well-formed, easy to pass
Loose
Very loose and watery
348.
Do you currently have diarrhea? This is a condition of recent onset which is different from your normal bowel movement pattern. If you always have loose stools, leave the default answer indicated.
Not applicable / don’t know
No
2 to 3 per day
3 to 4 per day
More than 5 movements per day
349.
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
350.
Do you have undigested fat in your stools?
No / don't know
Occasionally
Often
351.
Do you have undigested food in your stools?
No / don't know
Occasionally
Often
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SYMPTOMS: MOUTH/ORAL
352.
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
353.
Do you have any kind of bad / abnormal taste in your mouth?
No / rarely / don't know
Yes, some
Yes, significant
354.
Do you have a bitter taste in your mouth, particularly after meals?
Other than mouth ulcers, do you have any tenderness or soreness inside your mouth?
No / don't know
Yes, some
Yes, significant
360.
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
361.
How much saliva do you generally produce?
My mouth is often very dry
My mouth is sometimes a bit dry
Normal / don't know / dry from medication
I always have plenty of saliva
Excess saliva, with a tendency to drool
362.
Are your teeth sensitive or tender?
No / don't know
Somewhat
Very
363.
Do your teeth in general tend to be loose?
Don't know
No
Possibly / slightly
Somewhat / moderately loose
Definitely / very loose
364.
How often do you floss your teeth?
Don't know
Never / rarely
Occasionally
Several times per week
Daily or more frequently
365.
Do you suffer from clenching or grinding of teeth (Bruxism)?
No / don't know
Mildly
Moderately
Seriously - some damage to teeth
Severely - extensive damage to teeth
366.
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
367.
How many mercury amalgam ("silver") fillings do you have?
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
368.
Have you had any mercury amalgam fillings removed?
No / don't know
1 to 3
4 to 6
7 to 10
More than 10
369.
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
370.
Do your gums bleed easily?
No / don't know
Somewhat
Very
371.
Have you been diagnosed with periodontal disease (gum recession)?
Don't know
No, not a problem
Minor problem - 1 or 2 pockets
Moderate problem - 2 to 5 pockets
Major problem - Many or deep pockets - teeth loose
372.
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
373.
Is your tongue sore?
No / don't know
Occasionally / a little
Often / very
374.
Is your tongue swollen?
No / don't know
Somewhat / occasionally
Very / often
375.
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
376.
Do you tend to have a black tongue?
Don't know
No
In the past only
Minor / occasionally
Significantly / often
377.
Does your voice tend to be...?
Very soft/weak
Softer/weaker than average
Average / don't know / I am mute
Louder/stronger than average
Very loud/strong
378.
Speech. Which word / phrase best describes the way you speak?
Slowly
Incoherently - people often don't understand me
Averagely - accurately / don't know
Rapidly
379.
Has your voice changed for no apparent reason?
No / don't know
Mildly
Moderately
Yes, a lot
Yes, almost beyond recognition
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SYMPTOMS: EYES/OCULAR
380.
Do your eyes itch often?
Don't know
No
Just occasionally
Quite often / moderately
Very often / severely
381.
Are your eyes often irritated? This may include a 'sandy-gritty' feeling, the sensation of a foreign object in the eye or permanently moist eyes (excess tears).
No / don't know
Mildly
Moderately
Severely
382.
Are your eyelids sometimes red?
Don't know
No
Mildly / occasionally
Moderately / often
Severely / all of the time
383.
Are the whites of your eyes bloodshot?
No / don't know
In the past only
Occasionally a little
Occasionally significantly or frequently a little
Frequently significantly
384.
Do you have discharges from your eyes?
Don't know
No
Mild / moderate
Serious
Severe
385.
Moistness of eyes. Do your eyes tend to be...?
Usually / very dry
Sometimes / slightly dry
About average / don't know
Sometimes / slightly moist
Usually / very moist, to the point of tearing
386.
Vision disturbances. Ignoring any long/short-sightedness, does your vision sometimes become blurry or otherwise distorted?
No / don't know
Occasionally / moderately
Often / severely
387.
Focus. Slowly bring a newspaper or book closer to your eyes. Without wearing glasses or contact lenses, approximately how far from your eyes is the page when the regular-size letters start to blur?
I can't to this test / don't know
Less than 4 inches (10cm)
4-11 inches (10-28cm)
12-36 inches (30-90cm or 1-3 feet)
Over 36 inches (90cm or 3 feet)
388.
What is the color of your eyes?
Very light blue or light gray
Lighter than average
About average / don't know
Darker than average
Very dark brown
389.
Do the whites of your eyes have more of a yellow (jaundiced) color to them than in previous weeks or months?
Don't know
No
Probably
Definitely
390.
Do you have dark circles / areas under your eyes?
No / don't know
Yes, some
Yes, pronounced
391.
Do you have bags under your eyes?
No / don't know
Yes, somewhat
Yes, pronounced
392.
Does the outside 1/3 of your eyebrow area have little or no hair growth? In other words, do your eyebrows fail to extend out to edge of your eyes?
No / don't know
Yes
393.
Are you experiencing any additional eye problems other than those mentioned above? Examples include pain, motion problems, visual changes, poor focusing, protrusion, eyelid problems, cataracts, glaucoma, macular degeneration, etc.
Don't know
No
Yes More questions later...
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Do you have a diagonal crease (wrinkle) on one or both of your earlobes? A crease may be partial (only partway across the earlobe) or full (completely across the earlobe).
No / don't know
Partial crease on one ear
Partial crease on both ears
Full crease on one ear, possibly partial on other
Full crease on both ears
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SYMPTOMS: NOSE/NASAL
401.
Do you regularly suffer from a runny or drippy nose?
Don't know
No
Occasionally
Yes, moderately
Yes, severely
402.
Do you suffer from nasal congestion, mucous that accumulates in the nose, or post-nasal drip?
No / don't know
Occasionally / moderately
Often / severely
403.
How moist is your nose when you are not ill and not suffering from an allergic reaction?
Too dry
Quite dry
Normal / don't know
Quite moist
Very moist - tends to run
404.
Has your ability to taste or smell decreased from what it used to be?
No / don't know
Somewhat
Yes, definitely
405.
Do you have sensations of unpleasant smells for no apparent reason?
No / don't know
Occasionally / moderate
Often / definite
406.
How often do you get nosebleeds?
Never / rarely / don't know
Occasionally
Often
407.
Does your nose / throat mucous, in general, tend to be...?
Sinusitis - have you had sinus headaches or sinus infections?
Never had it / don't know
Probably had it/minor episode(s) now resolved
Major episode(s) in the past, no longer a problem
Current minor / chronic problem
Current major / chronic problem
410.
Has your nose grown abnormally large over the years? Do not include the effects of traumatic injury or a current infection that has caused swelling.
Don't know
No
Mildly
Moderately
Significantly
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GLOSSARY
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: Also known as Aphthous Ulcers, these are 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.
Cataract: A steadily worsening disease of the eye in which the lens becomes cloudy as a result of the precipitation of proteins. Most cataracts are caused by the functions of the body breaking down. Eye trauma, such as from a puncture wound, may also result in cataracts.
Chapped: Roughened, reddened, or cracked skin, especially as a result of cold or exposure.
Cold Sore: Also known as fever blisters, cold sores are 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.
Constipation: Difficult, incomplete, or infrequent evacuation of dry, hardened feces from the bowels.
Diarrhea: Excessive discharge of contents of bowel.
Glaucoma: A disease of the eye characterized by vision loss due to an increase in the pressure of fluid within the eye. This rise in pressure results from a build-up of aqueous fluid and leads to progressive damage to the optic nerve that transmits visual signals to the brain. Over time, glaucoma can lead to a gradual loss in peripheral vision. There are usually no signs that you're developing glaucoma until vision loss occurs.
Laxative: 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.
Macular Degeneration: Increasingly poor eyesight often accompanied by light sensitivity, distorted vision and a blank or dark patch in the center of vision.
Meniere's Disease: An affliction of the middle ear characterized by vertigo, nausea, vomiting, tinnitus and progressive deafness.
Otitis Externa: Also called Swimmer’s Ear, this is an infection of the outer ear canal caused by either fungus or bacteria. Water that remains trapped in the ear canal (when swimming, for example) can provide a breeding ground for these bacteria and fungi. Symptoms include redness of the outer ear; itching in the ear; pain, especially when touching or wiggling the earlobe; drainage from the ear; swollen glands in the neck; a swollen ear canal; hearing loss.
Otitis Media: A very common condition involving inflammation of the middle ear and can be classified as either acute otitis media (AOM), or otitis media with effusion (OME) which is a chronic disease. It most commonly affects infants and young children but can affect all age groups. Symptoms of AOM include earache, decreased hearing, fever, unsteadiness, and occasionally liquid discharge if the eardrum bursts. Symptoms of OME include decreased hearing, tinnitus and unsteadiness, but OME can be entirely without symptoms. Effusions (discharges) continue for several weeks after AOM; only 60% of ears with AOM are clear at 2 weeks and 80% are clear by 8 weeks.
Polyp: A usually nonmalignant growth or tumor protruding from the mucous lining of an organ such as the nose, bladder or intestine, often causing obstruction.
Post-Nasal Drip: A constant flow of mucous and discharge down the "back of the throat", generally caused by acute infection or allergies. This drip can in turn be responsible for the development of a secondary cough due to irritation of the larynx, and bronchospasm in asthmatic individuals.
Tinnitus: A sensation of noise (ringing or roaring) that is caused by a bodily condition and can usually only be heard by the person affected.
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