Functional Health Risk Assessment Questionnaire

Functional Health Risk Assessment Questionnaire helps you to determine the levels of dysfunction or burden on various system and/or organs. The burden or dysfunction in any organ/system is accompanied by various symptoms mentioned in this questionnaire.

After assessment you will be able to the see the system burden in percentage values and take necessary step to correct it. This questionnaire helps us to find out various imbalances, deficiencies and malfunctions which can increase the future risk of certain diseases or ill health.

The questionnaire is not able to diagnose, treat or cure any disease. These symptoms are based upon the ideology of functional medicine and nutritional assessment techniques in holistic health care practice. RH+ use this questionnaire and other forms of assessments including blood reports to devise an individual health care program to address various health issues as advised by Institute of Functional Medicine.

Tell us who you are

Name

D.O.B

Sex

Male

Female

Step 1 / 8

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Rating scale:
0 - Never
1 - Effect is mild or happens 1-2 times in a month
2 - Effect is moderate or happens more than 1-2 times a week
3 - Effect is very severe or happens daily

1. Acidity/heart burn/acid reflux

2. Bloating or Gas or Belching within one hour after eating

3. Chronic anaemia or low iron

4. Feel like skipping breakfast

5. Fingernails, chip peel or break easily

6. Vegan Diet (no dairy, no meat, no eggs)

Yes

7. Bad breath

8. Sleepy after meals

9. Sweat has strong odour

10. Rosacea (acute redness on cheeks and/or nose)

11. Excessive fullness after meals

12. Frequent use of Antacids

13. Chronic B12 deficiency

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Step 2 / 8

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Rating scale:
0 - Never
1 - Effect is mild or happens 1-2 times in a month
2 - Effect is moderate or happens more than 1-2 times a week
3 - Effect is very severe or happens daily

1. Stomach upset with oily or greasy foods

2. Greasy stools

3. Wine makes you feel sick or intoxicated

Yes

4. Piles/Hemorrhoids/Varicose veins

5. Sensitive to strong smells or fragrances

6. Gall bladder issue (stones/pain)

Yes

7. Blood pressure above 120/80

8. High Total and / or LDL cholesterol

9. Alcohol per week

< 0 ml

< 00 ml

< 200 ml

> 200 ml

10. Sensitive to tobacco smoke

11. Dry Skin/Itchy feet/Skin peels on the feet

12. Pain between shoulder blades

13. Migraine or Headaches

Step 3 / 8

1. Autoimmune disease

Yes

2. Wheat, Gluten or Dairy sensitivity

3. Asthma, sinus, blocked nose

4. Allergy or sensitivity to multiple foods

5. Allergic to dust, pollen or mold

6. Stomach bloats 1-2 hour after meal

7. Crave bread, pasta, cheese or starches (rice, potato)

8. Alternating Constipation and diarrhoea

9. Strong addiction/repulsion to certain foods

Yes

10. Vivid or scary dream, nightmares

11. Frequent or long term use painkillers (paracetamol containing products)

12. Stuffy head or congestion in head

13. Muscle loss or Low protein

Step 4 / 8

1. Fungal or yeast infections

2. Vaginal infections (female only)

3. Recurrent UTI infections (female only)

4. All 3 above infections reappears or aggravate with starch and sugar consumption

5. Smelly stools

6. Foul smelling lower bowel gas

7. Anal Itching

8. Stools are not well formed (broken, semiliquid, small pieces, edges or ribbon shaped)

9. Colitis/IBS/IBD

10. White coating on tongue (especially on the middle and back portion)

11. Nail fungus and/or hair fungus

12. Bad breath or smelly sweat or body odours (which is difficult to mask with perfume or mouthwash)

13. Tender points or painful along outer side of thigh (IT band)

14. Stools are hard or difficult to pass

15. Less than one bowel movement per day

16. Frequent or long term antibiotic use

Not more than once a year

Not more than twice a year

Greater than twice a year

Continues use for more than a week or 4 times or more in a year

17. Use of oral contraceptive pills

Yes

18. Inflamed body or joints

19. Obese or Overweight

Yes

Step 5 / 8

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Rating scale:
0 - Never
1 - Effect is mild or happens 1-2 times in a month
2 - Effect is moderate or happens more than 1-2 times a week
3 - Effect is very severe or happens daily

1. Wake up few hours after falling asleep, difficult to get back to sleep again

2. Family members with Diabetes

3. Binge or uncontrolled eating (snacking throughout the day)

4. Black rough skin on ankles/elbows or black circle on neck

5. Feel sleepy after meals (especially after lunch and/or high carb meals)

6. Crave sweet

7. Obese or overweight or Fat around waist/abdomen

8. Need Caffeine or sugar in afternoon

9. Sweet tooth

10. Dental cavities

Yes

11. Fatigue and/or shaky if meals are skipped or delayed

12. Frequent thirst

13. Frequent urination

14. Big appetite

15. Hogging (during eating)

Step 6 / 8

1. Difficulty falling asleep

2. Low energy after waking up

3. High blood pressure (>120/80 mmHg)

4. Low Blood pressure (<100>

5. Feel energetic after 4-5pm

6. Crave salty foods

7. Joint pain or inflammation

8. Tendency to wear sunglasses in sun

9. Weakness, dizziness

10. Dizziness when standing up suddenly

11. Mood fluctuations during day

12. Cravings in between the meals

13. Addiction to stimulants (e.g caffeine)

14. Long term use of pre workouts (caffeinated)

15. Ankle sprains

Step 7 / 8

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Rating scale:
0 - Never
1 - Effect is mild or happens 1-2 times in a month
2 - Effect is moderate or happens more than 1-2 times a week
3 - Effect is very severe or happens daily

1. Depression

2. Numbness, tingling in hands and feet

3. Restless leg syndrome

4. Nervousness or agitation

5. Anxiety

6. Nose or gum bleeding

7. Excessive soreness after exercise

8. Slow recovery from workouts

9. Cramps in foot, toe or calves at rest

10. Crave chocolate

11. Pain or swelling in joints

12. Feet have strong odour

13. Sweaty palms and/or feet

14. Dry mouth, eyes or nose

15. White spots on fingernails

16. Weak or brittle nails

17. Dandruff

18. Skin easily get tanned

19. Headache with sun exposure

20. Crave fatty foods (cheese, butter etc)

21. Easily fatigue with moderate exertion

22. Weakness or excessive sleep

Step 8 / 8

Rate each of the following symptoms based upon your typical health for the past 1-2 months

Rating scale:
0 - Never
1 - Effect is mild or happens 1-2 times in a month
2 - Effect is moderate or happens more than 1-2 times a week
3 - Effect is very severe or happens daily

Please provide your email and contact details

Contact Number

Functional Health Risk Assessment Questionnaire

Tell us who you are

Step 1 / 8

Step 2 / 8

Step 3 / 8

Step 4 / 8

Step 5 / 8

Step 6 / 8

Step 7 / 8

Step 8 / 8

Please provide your email and contact details

Contact Detail

Subscribe To Our Blog

Get In Touch