Congratulations on taking your first step to change your life by understanding what stress is doing to your body!  This questionnaire will take about 20 minutes.  We will discussed your answers during our appointment.

Name *
Section 1 - Functional Indicators
Eyes are sensitive to bright lights, need to wear sunglasses for comfort.
Tightness in throat, painful “lump” occasionally. *
Form “gooseflesh” easily, sweat without temperature rise, “cold sweats.” *
Voice rises to high pitch or is lost during stressful moments (arguments, public appearances, etc.). *
Easily shaken up, easily startled, heart pounds hard from unexpected noise. *
Prefer being alone, uneasy when “center of attention.” *
Blood pressure fluctuates, has been “too high” on occasion. *
Asthma or wheezes (from ________________ ). *
Section B
Have always had low or normal blood pressure. *
Known as “perfectionist” or come from “high-strung family.” *
Tend to work off worries, something left undone causes unusual concerns. *
Tend to avoid complaints, try to ignore discomforts and inconveniences. *
Have had frequent or severe attacks of pneumonia, bronchitis, flu, sinusitis, or colds. *
Have had allergic responses such as skin rash, dermatitis, hay fever, severe sneezing attacks, asthma, etc. *
Emotional storms cause exhaustion (must go lie down under heavy stress). *
Perspire excessively. *
Skin takes on a brownish color, brown spots on skin (“liver spots”). *
Painful finger joints, rheumatoid arthritis, or morning stiffness. *
Secion C
Persistent high blood pressure. *
Stronger than average physically. *
Strong feelings, tendency to “blow up,” dislike of being crossed. *
FEMALE: Excessive hair on face, arms, and legs, appearance on masculine side.MALE: Baldness, excessive hair on arms and back, muscular square build, aggressive in business and sports. *
Section D
Unable to hold your breath for 20 seconds (use second hand on watch to time). *
Sigh and yawn frequently. *
Have a feeling of suffocation, open windows in closed rooms. *
Feel short of breath at times, even though not exercising. *
Feel breathless when under stress. *
Breathe loudly (people notice), heard breathing in quiet rooms. *
Gastrointestional Indications - Section A
Distress from fats or greasy foods (nausea, dizziness, headaches, etc.). *
Distress from onions, cabbage, radishes, cucumbers (bloating, gas, etc.). *
Stool appears yellow or clay-colored, is foul-odored, shows undigested foods. *
Skin is grayish, pasty, oily on nose and forehead. *
Have had jaundice, hepatitis. *
Bad breath, bad taste in mouth, body odor (including feet). *
Unusual redness on palms of hands. *
Unaccountable burning on soles of feet. *
Varicose veins, hemorrhoids (“piles”), phlebitis, veins showing on chest or stomach (blush areas). *
Able to go all day without urinating, diminished urination. *
Long history of constipation. *
“Flabby” flesh, underarm or stomach hangs. *
Section B
Indigestion 2 to 3 hours after each meal (fullness, bloating, sourness, etc.). *
Heavy, full loggy feeling after eating a meat meal. *
Loss of former taste or craving for meat. *
Excessive lower bowel gas (flatulence). *
Long history of being anemic, frequent treatment for anemia. *
History of constipation alternating with diarrhea (bowels “too loose or too tight”). *
Section C
Stomach pain occurs after eating, especially at night, and is relieved by drinking milk or cream. *
Above symptoms flare up in spring and fall of the year (seasonal occurrence). *
Have been told you have stomach “ulcers.” *
Above symptoms aggravated by worry and tension, relieved by vacationing. *
Section D
Diarrhea occurs frequently or is resistant to treatment. *
Roughage in diet aggravates diarrhea. *
Mucous shreds appear in stool. *
Have more than three bowel movements per day. *
Have been told you have ulcerative or mucous colitis. *
Section E
Indigestion occurs soon after eating. *
Indigestion is acute, comes on suddenly. *
Indigestion is relieved by soft drinks. *
Have difficulty belching, stomach cramps, colicky, “butterfly” sensations in stomach. *
Above symptoms aggravated by stress. *
Section A Hormonal Indications
Muscles stiff in the morning, feel a need to limber up, feel “creaky”after sitting still for a period of time. *
Feel dizzy or nauseated in the morning. *
Experience motion sickness when traveling, dizziness when changing up and down positions. *
Heart occasionally seems to miss beats or “turn flip flops.” *
The following symptoms are worse at night: coughing, hoarseness, muscle cramps. *
Insomnia, restlessness, failing memory, forgetfulness. *
Feel better in afternoon, worse in morning. *
Have an unusual craving for salt. *
Section B
“Go to pieces” easily, dislike working under pressure or being watched, cry easily. *
Gain weight, fail to lose on diets, tend to “retain water” easily. *
Long history of chronic constipation. *
Feel better mornings, worse afternoons. *
Difficulty concentrating, easily distracted. *
Outer third of eyebrow hair unusually thin or missing. *
Section C
Heartbeats above 90 beats per minute when at complete rest. *
Protruding tongue quivers (check in mirror), hands shake, tremor (hold paper to check). *
Energy spurts followed by exhaustion (repeated in cycles). *
Have strong, healthy teeth. *
Have a good appetite, but fail to gain weight in spite of food increase. *
Have fine features, thin skin, thin hair. *
Erratic behavior, “flighty.” *
Poor balance (close your eyes and stand on one leg). *
Section Hormone/Enzyme Indicator
Muscle weakness, weak grip, weak legs, objects feel unusually heavy. *
Muscle wasting *
Sharp pains in chest after exercising. *
Numbness or loss of sensation. *
Night sweats, wake up frightened. *
Objects fall from hands, reach in the wrong places for things. *
Blurred vision, bloodshot eyes, feeling of sand or grit in eyes. *
Redness or irritation of nostrils, corners of mouth cracked, irritated. *
Lost or diminished sex drive. *
Section Hormone/Enzyme Indicator (FEMALE ONLY)
Irregular or uncomfortable menstrual periods.
Menopause symptoms (hot flashes, etc.).
Before periods, feel nervous, depressed, “bloated.”
Unable to have children because of sterility (not age or operation).
Male Hormone/Enzyme Indicator ( MALE ONLY)
Difficulty urinating (slow starting, burning during, need to get up at night).
Associate the above with back or leg pains or with constipation.
Have/had prostate trouble or surgery.
Have/had painful, green, or mucous discharge from the penis.
Muscle weakness, weak grip, weak legs, objects feel unusually heavy.
Section Fluid / Balance Indications
Feel drowsy, chronic fatigue. *
Cold hands and feet, wear extra clothing, bedclothing, use heating pads to keep warm. *
Short of breath climbing stairs. *
Require extra sleep. *
Feel better when resting, lowered endurance, low exercise tolerance. *
Section B
Have been treated for heat prostration, feel uncomfortable in or dislike hot weather. *
Ankles swell in hot weather. *
Ankles swell in afternoon, improve in morning. *
Perspire excessively in hot weather (more than others). *
Use very little salt, restricting salt in diet. *
Section Skin/Immune System Indications
Bruise easily, “black and blue spots.” *
Have/had protein or albumin in urine, kidney trouble. *
Irritated skin, chapped lips, cracked skin on hands. *
Fungus under nails of hands or feet. *
Skin is rough, dry, scaly, or “lumpy.” *
Discharge from eyes, “sand” on lids in the morning. *
Burning or itching when urinating. *
Swelling of glands in neck (salivary). *
Swelling of lymph glands. *
Inability to adjust eyes when entering dark room or theater. *
Night sweats. *
Section Food/Environment Indicators
Nervousness, shaky feeling, or headaches are relieved by eating sweets. *
Irritable if late for a meal or miss a meal, irritable before breakfast. *
Experience sudden strong craving for sweets or alcohol. *
Get hungry “five minutes after eating.” *
Often wake up at night feeling hungry. *
Section B
Night sweats, increased thirst. *
Chronic fatigue, lowered resistance. *
History of boils, leg sores, or lesions taking a long time to heal. *
Overweight, trouble losing weight (1 = 5-15 pounds, 2 = 15-25 pounds, 3 = >25 pounds overweight). *
Experience “pickup” from exercising. *
Have/had sugar in urine, diabetes. *
Member of family has diabetes. *
Crave sweets, but eating them does not relieve symptoms. *