Name *

First Name

Last Name

Checklist 1

Check each statement that has applied THROUGHOUT YOUR LIFE -- Checklists 1-3

My lifelong tendency has to be thin/lanky

I find having a routine in life challenging

My skin tends to be rough, dry

My joints are fairly prominent

My teeth are protruded and/or crooked

My hair is kinky, curly, and tends to be dry or frizzy

It is usually easy for me to lose weight & I usually have diffculty gaining weight

I usuallly enjoy hot weather

I tend to dislike wind

I tend to dislike very dry climates

Checklist 2

I have a medium build with medium bone structure

I enjoy competitive activities & enjoy physical or intellectual challenges

My teeth are medium-sized and/or a littel yellow (not stained)

I have fair skin that sunburns easily

I have lots of moles or freckles

I have greyed early, deal with balding, or have thin fine hair

My eyes are sensitive to light

I prefer a cool climate to a warm one

I dislike heat; especially humis heat, and feel easily fatigued by it

I have a sharp, intelligent, aggressive mind

Checklist 3

I have a sturdy constitution with a large bone structure

I have had a lifelong tendency to always be at least a little overweight

My teeth are naturally large, straight, and white

My hair is thick and lustrous

My eyes are large with long, full, luxurious lashes

If given the opportunity, I can eaasily sleep deeply for 8-10 hours per night

I gain weight easily & have difficulty losing weight

My facial features are rounded with full, moist lips

I tolerate most climates well, but have usually preferred hot, dry weather

My energy & stamina are consistent. When I have a lot to do, I do it at a pace that can maintian for a long time

Checklist A

Check each statement that applies to you AT THIS TIME, PRESENTLY -- Checklists A-C

I have been feeling nervous, fearful, panicky, anxious, or frantic

I have twitches, tics, tremors, or spasms in my body & I fidget a lot

My skin is dry and easily chapped

I have been suffering from dry, hard stools, constipation, gas, or bloating, or I have been having loose stools due to emotional upset

I feel I am underweight

Lately, I have a stronger dislike of the wind and cold than usual

I have a difficult time tolerating loud noise

My sleep has been light, interupted, restless, or disturbed

I feel scattered, spacey, and have difficulty concentrating, or have poor memeory

I am prone to overthinking or worrying

Checklist B

I have red, inflamed, or burning rash, acne, or fever blisters

There is accute inflammation in my body or joints

I have acid reflux, heartburn, acid indigestion, or a gastric or peptic ulcer--or a tight, burning feeling in my stomach or digestive tract

I feel nauseated or uncomfortable if I miss a meal

I have been having loose stools that are not due to emotional upset

I have been feeling uncomfortably warm or hot

I have been feeling frustrated, irritable, or angry

I can be easily judgemental, impatient, critical, or intolerant to others

My eyes have been red, bloodshot, inflamed, or sensitive to light

I expect perfection of myself or others

Checklist C

I have excess mucus in my body or nasal passages or lung congestion

I have a thick, white coating on my tongue

My bowel movemenrts are slow, sticky, sluggish, or feel incomplete

I am overweight

It is difficult for me to wake up in the mornings, even if I sleep 8-10 hours, and I feel lethargic throughout the day

I have been feeling slow, foggy, dull, lethargic, or heavy

In the morning I have to cough up a lot of mucus

I have a deep, wet cough that produces a lot of mucus

I feel complacent, stubborn, and resistant to any change--or my close friends and family tell me that I am very slow to change or to make a decision

I am prone to excessive emotional eating, especially sweet, heavy foods