Protected: Health Questionnaire Form This content is password protected. To view it please enter your password below: Password: Health Questionnaire #1 Fields marked with a * are required. Name * Today's Date * Email * I have completed the Health Assessment Form. * Please complete the following questionnaire on a scale of 1-6, with 1 =does not apply, 3 =applies sometimes, 6 =applies most 1. I perform activity very quickly 2. I am not good at memorizing things and then remembering them later 3. I am enthusiastic and vivacious by nature 4. I have a thin physique - I don’t gain weight very easily 5. I learn new things easily 6. My characteristic gait while walking is light and quick 7. I tend to have difficulties making decisions 8. I tend to develop gas or become constipated easily 9. I tend to have cold hands and feet 10. I become anxious or worried frequently 11. I don’t tolerate cold weather as well as most 12. I speak quickly and my friends think I’m talkative 13. My moods change easily and I am somewhat emotional 14. I often have difficulty falling asleep or having a sound night's sleep 15. My skin tends to be dry, especially in the winter 16. My mind is very active, sometimes restless, but also very imaginative 17. My movements are quick and active, my energy tends to come in bursts 18. I am easily exciteable 19. Left on my own, my eating and sleeping habits tend to be irregular 20. I learn quickly but also forget quickly TOTAL SCORE Health Questionnaire #2 Please complete the following questionnaire on a scale of 1-6, with 1 =does not apply, 3 =applies sometimes, 6 =applies most 1. I consider myself to be very efficient 2. In my activities, I tend to be precise and orderly 3. I am strong minded and have a somewhat forceful manner 4. I feel uncomfortable or become fatigued in hot weather 5. I tend to perspire easily 6. Even though I might not always show it, I become irritable or angry quite easily 7. If I skip a meal or a meal is delayed, I become uncomfortable 8. One or more of the following describes my hair, early graying or balding, thin, fine straight hair, blond, red or sandy hair 9. I have a strong appetite; if I want to I can eat a large quantity 10. Many people consider me stubborn 11. I am very regular in my bowel habits - it would be more common for me to have loose stools than constipation 12. I become impatient easily 13. I tend to be a perfectionist about details 14. I get angry quite easily, but then quickly forget about it 15. I am very fond of cold foods like ice cream and also crave ice cold drinks 16. I am more likely to feel a room is too hot than too cold 17. I don’t tolerate foods that are hot or spicy 18. I am not very tolerant of disagreement 19. I enjoy challenges and when I want something, I am very determined in my efforts to get it 20. I tend to be critical of others and also of myself TOTAL SCORE Health Questionnaire #3 Please complete the following questionnaire on a scale of 1-6, with 1 =does not apply, 3 =applies sometimes, 6 =applies most 1. My natural tendency is to do things in a slow and relaxed fashion 2. I gain weight more easily than most people and I lose it more slowly 3. I have a more placid and calm disposition - I'm not easily ruffled 4. I can skip meals easily without any discomfort 5. I have a tendancy towards excess mucus, phlegm, chronic congestion, asthma, or sinus problems 6. I must get at least eight hours of sleep in order to be comfortable the next day 7. I sleep very deeply 8. I am calm by nature and not easily angered 9. I don’t learn as quickly as some people, but I have an excellent long term memory 10. I have a tendency towards gaining weight - I store extra fat easily 11. Weather that is damp and cool bothers me 12. My hair is thick, dark, and wavy 13. I have smooth, soft skin with a somewhat pale complexion 14. I have a large, solid body build 15. The following describe me well: Serene, sweet-natured, affectionate, forgiving 16. I have slow digestion, which makes me feel heavy after eating 17. I have very good stamina and physical endurance and a steady level of energy 18. I generally walk with a slow measured gait 19. I have a tendency towards oversleeping, grogginess upon waking and am generally slow to get going in the morning 20. I am a slow eater and am slow and methodical in my actions TOTAL SCORE