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 .
Blood
Pressure
Heart
Are you concerned about....?
Are you concerned about....?
Nosebleeds
Feel jittery
Headaches typically
in the morning
Heartburn that moves
to neck, jaws, left shoulder and arm
Weak, fatigued, nervous
First effort of the
day causes pain around chest
Ringing in the ears
Dizziness
Dizziness, drowsiness
Choking, smothering
sensation
Blushing, no apparent
reason
Minor exertion exhausts
Numbness,
tingling in the hands and feet
Heart pounds easily
Blurred vision
Heavy sweating (no exertion)
High blood pressure
Mild or severe chest
pain, especially during exercise
Total the number
of ticks and put in the box Wheezing or dry cough
Heart palpitations,
slow, rapid or irregular
Swelling in the feet,
ankles, legs, comes and goes
Veins on neck are prominent
High blood cholesterol
Total
the number of ticks and put in the box
Prostate
Reproduction
Are you concerned
about....?
Are
you satisfied with....?
Frequent or urgent need
to urinate
Itchy patches
around inner thigh and groin
Delayed, weak or interrupted
urine stream
Itching
at night
Pain or burning upon
urination
Painful
testicles
Urge to urinate several
times a night
Difficult
attaining and/or maintaining an erection
Rose coloured (bloody)
urine
Low sexual
drive
Difficulty urinating
Premature
ejaculation
A sense of bladder fullness
Low energy
level or stamina
Ejaculation causes pain
Inflammation
on the head of the penis
Blood in the semen
Genital
and/or rectal rash or irritation
Lack of sex drive, impotency
Distorted
nail growth
Impotency
Loses of
pubic or armpit hair
Pain or fatigue in the
legs or back
Infertile
Dripping after urination
Low sperm
count, low sperm mobility
Increased straining
with small amounts of urine passed
Unexplained
weight gain
Anemia
Testicles
appear smaller
Total the
number of ticks and put in the box Development
of breasts or nipple tenderness
Feeling
of heaviness or hardness in testicles
Sparse
beard or slow hair growth
Decreased
body hair
Fine wrinkling
in corner of mouth or around eyes
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.
