Click the Tick Box to accept the condition that applies
to you. This survey covers four major areas:
At the completion of the survey count the number of
responses you have ticked and click here to see the interpretation .
Are you concerned about.....?
Are you concerned about....?
Excessive belching, burping &/or
bloating
Fatty foods cause indigestion
Gas immediately after meals
Feel restless, agitated, angry
Indigestion and fullness 2 - 4 hours
after eating
General feeling of poor health
Excessive gas or bloating
Feeling of extreme dryness
Abdominal cramping, aches and pains
Dry, flaky skin and/or hair
Specific foods and beverages
aggravate indigestion and cause bloating
Bags or dark circles under eyes
Roughage or fibre cause constipation
Deterioration of eyesight, spots
Stool - undigested food present
Yellowish colour of skin or eyes
Stool - yellow and foul smelling
Headaches
Painful, difficult straining during
bowel movements
Insomnia
Crave sugars/sweets/breads or alcohol
Sinus Problems
Frequent or urgent urination
Excess mucous function
Bad breath and/or body odour
Chronic coughing
Antibiotic use 4 or more times/year
Sore throat, hoarseness, loss of voice
Long term antibiotic use, greater than
1 month
Swollen or discoloured tongue, gums or lips
On birth control pill for more than
2 years
Rapid or pounding heartbeat
Athlete's foot, ringworm or any chronic
fungal infection of the skin or nails?
Asthma, bronchitis
Total the
number of ticks and put in the box
Pain or aches in joints
Pain or aches in muscles
Hives, rashes or itchy skin
Anxious or depressed (mood swings)
Do you....?
Poor concentration and/or memory
Have inadequate energy or fatigue
Exposure to perfumes, tobacco smoke, exhaust fumes or
other chemical symptoms
Suffer from Chronic Fatigue Syndrome
Total the
number of ticks and put in the box
Find it hard to get up or become motivated in the morning
Often feel tired or overworked
Experience mental confusion or sluggishness
Total the
number of ticks and put in the box
Are you satisfied with....?
The way your body feels
The way your body looks
Your body fat
Are you satisfied with....?
Your muscle tone
The way your body feels
Your strength
The way your body looks
Your endurance
Your body fat
Your flexibility
Your muscle tone
Your attractiveness
Your strength
Your present weight
Your endurance
Total the
number of ticks and put in the box
Your flexibility
Your attractiveness
Your present weight
Total the
number of ticks and put in the box
It is not possible to allocate scores and relate them
to your health. If the number of ticks in your survey appears too high
you have a deep desire to improve your health. Why not Contact
us at the Hervey Bay Wellbeing centre with your concerns.
