Name
*
First Name
Last Name
Email
*
Age
*
What kind of climate do you live in?
*
a) Dry and Cold
b) Hot and Humid
c) Humid and Cold
The weather I am happiest in
*
a) Warm and Sunny
b) Cool mild weather
c) Any as long as it is not humid
My physical body make up is
*
a) Thin and either tall or short
b) Medium built and well proportioned
c) Large with an ample build
As a child I was
*
a) Thin
b) Medium built
c) Overweight
My lifelong tendency with weight has bee
*
a) I typically don’t gain weight easily, or I have trouble keeping it on
b) I can gain or lose weight easily, depending on what I focus on I tend to gain weight easily and can have difficulty losing it
c) I tend to gain weight easily and can have difficulty losing it
Most of my life, my body temperature has felt:
*
a) Cold—my hands and feet are usually cold and I prefer warm environments
b) Warm—I am usually warm regardless of the season and prefer cool environments
c) Comfortable—I am adaptable to most temperatures
My joints are
*
a) Protruding, or cold and make popping or cracking sounds
b) Moderate in size and can feel hot or inflamed
c) Large and well lubricated, move with ease
My nails are
*
a) Brittle
b) Sharp or flexible
c) Thick or oily and smooth
My hands and feet tend to be
*
a) Cold
b) Warm
c) Perspire but feel cool or cold
When I Speak
*
a) I speak rapidly and use my hands
b) I get to the point and my voice tends to carry
c) I have a slow and monotonous speech
My mental activity tends to be
*
a) Hyperactive
b) Moderate
c) Slow
My thoughts tend to be
*
a) Fast and change easily
b) Clear and I like to share them
c) Steady and slow to change
When I am stressed
*
a) I feel anxious
b) I feel anger and irritability
c) Tend to run away from stressful situations
My memory tends to be
*
a) Recent memory good, but tend to forget
b) Good distance memory
c) Slow and sustained memory
In projects I am a
*
a) Creative thinker
b) Initiator and leader
c) Make sure project runs smoothly
When it comes to routine I
*
a) Dislike routine, flexible and spontaneous—I like to mix it up
b) Enjoy planning and routines, goal-oriented and challenging—I enjoy long, productive days
c) Works well with routine, predictable and steady—I’m good at keeping a routine and like structured days
Overall, my temperament is
*
a) Enthusiastic – I enjoy trying new thing
b) Purposeful – I am goal-oriented
c) Easygoing – I like to go with the flow
Most of my life, I have made choices
*
a) Spontaneously and spur of the moment based on how I’m feeling at the time
b) Precisely and confidently after researching options
c) Slowly, or I am fine letting others make the choices
I believe money is meant to be
*
a) Spent
b) For special items
c) Saved
In general, my stamina over the day is
*
a) Mild—I tend to start strong with lots of energy, but lose steam
b) Average—but I can push myself with a mind-over-matter attitude when needed
c) Enduring—I have great stamina but don’t typically like to test it
My lifelong tendency with sleep has been
*
a) I am a light sleeper and awaken easily
b) I sleep soundly for shorter periods of time than most people
c) I enjoy deep, long sleep
My favorite kind of exercise is
*
a) Dance, flowing movement or yoga
b) Competitive exercise such as sports or weight lifting
c) Leisure activities such as walks
When I exercise, I
*
a) Sweat a small amount, with little to no smell
b) Sweat a lot, with a strong or fleshy smell
c) Moderate sweat with a sweet smell
In general, my appetite is
*
a) Inconsistent—my hunger fluctuates, or sometimes forget to eat
b) Strong—I feel ravenous and can get irritable if I eat late; I don’t like to skip meals
c) Steady—I tend to feel full for a while after meals and can comfortably delay eating if I need to
When I eat, I like
*
a) To snack or nibble, light foods
b) High protein foods
c) Fatty or starchy food
My digestion currently is
*
Indicate which has been the most common in the last 6 months.
a) Irregular and tend to gas
b) Quick and sometimes burning
c) Prolonged and sometimes mucous
My bowel movements are
*
Indicate which has been the most common in the last 6 months.
a) Irregular, dry or hard
b) Loose and broken
c) Thick oily or sluggish
When I wake up, I
*
Indicate which has been the most common in the last 6 months.
a) Have hunger sometimes
b) Have hunger
c) Don't have hunger
In general, I have
*
a) Changeable thirst
b) Surplus of thirst and want cool drinks
c) Hardly any thirst
My sleep is
*
a) Broken up and scanty
b) Little but sound
c) Deep and prolonged
When I dream, they are
*
a) Quick and active
b) Action packed or violent
c) Romantic with things such as lakes or snow
If I am ill I tend to have
*
a) Nervous disorders and/or pain
b) Fevers and/or rashes and/or inflammation
c) Fluid retention and/or mucous/congestion
Please indicate any of the following you may be experiencing; constipation, diarrhea, sinking stools and/or mucus in stool, sticky stools, indigestion, fatigue after eating, bloating; gas, heartburn, bad breath.
*
Please indicate any of the following you may be experiencing; fatigue, low energy, weakness, unclear thinking, grogginess.
*
Please indicate any of the following you may be experiencing; aches and pains, poor circulation, joint pain and inflammation.
*
Please indicate any of the following you may be experiencing; skin inflammation, psoriasis, dandruff, boils, acne.
*
Please indicate any health concerns:
*
Please indicate any allergies:
*
Please indicate your main health goals:
*
Is there anything else you would like to share with us?