Mind Body Questionnaire


    Section 1

    Choose which statement best describes you.

    Frame


    Weight


    Eyes


    Complexion


    Hair


    Joints


    Sleep Pattern


    Body Temperature


    Temperament


    Under Stress...


    Section 2

    Using the following scale, indicate how well each statement applies to your life experiences over the past thirty to sixty days .

    I’ve been feeling worried or anxious. 1 - Not at All2345 - Very
    I’ve been having difficulty falling asleep or have been awakening easily. 1 - Not at All2345 - Very
    I’ve been feeling restless if I’m not constantly on the move. 1 - Not at All2345 - Very
    I’ve been acting impulsively or inconsistently. 1 - Not at All2345 - Very
    I’ve been more forgetful than usual. 1 - Not at All2345 - Very


    My daily schedule of eating meals, going to sleep or awakening has been inconsistent from day to day. 1 - Not at All2345 - Very
    My digestion is irregular with gas or bloating. 1 - Not at All2345 - Very
    My bowel movements have been hard, dry or occurring less than once per day. 1 - Not at All2345 - Very
    My skin has been dry or flaky. 1 - Not at All2345 - Very
    I’ve been having a number of physical concerns. 1 - Not at All2345 - Very


    I’ve been feeling irritable or impatient. 1 - Not at All2345 - Very
    I’ve been feeling critical and intolerant. 1 - Not at All2345 - Very
    I’ve been feeling compulsive, with difficulty stopping once I’ve started a project. 1 - Not at All2345 - Very
    I’ve been strongly opinionated freely sharing my point of view without being asked. 1 - Not at All2345 - Very
    I’ve been easily frustrated by other people’s incompetence. 1 - Not at All2345 - Very


    My skin has felt hot and irritable, or has been breaking out easily. 1 - Not at All2345 - Very
    Spicy foods, while I might enjoy them, have not been agreeing with me. 1 - Not at All2345 - Very
    I’ve been having acid indigestion or heartburn. 1 - Not at All2345 - Very
    I’ve been feeling overheated, have had a low grade fever, or have been having hot flashes. 1 - Not at All2345 - Very
    My bowels have been loose or moving more than twice per day. 1 - Not at All2345 - Very


    I’ve been dealing with conflict by withdrawing. 1 - Not at All2345 - Very
    I’ve been accumulating clutter in my life. 1 - Not at All2345 - Very
    I’ve been maintaining my routine and feeling resistant to changing my pace. 1 - Not at All2345 - Very
    I’ve been having difficulty leaving a relationship, job, or situation even though it is no longer nourishing me. 1 - Not at All2345 - Very
    I’ve been spending more time watching than participating in athletic activity. 1 - Not at All2345 - Very


    I’ve been holding onto extra pounds. 1 - Not at All2345 - Very
    I’ve been having difficulty getting going in the morning. 1 - Not at All2345 - Very
    My digestion has been slow or I’ve been feeling heavy after meals. 1 - Not at All2345 - Very
    I’ve had sinus congestion or excessive phlegm in my respiratory tract. 1 - Not at All2345 - Very
    I’ve been feeling drowsy or sluggish after meals. 1 - Not at All2345 - Very


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