Mind Body Questionnaire


    Physical Characteristics

    Choose which statement best describes you.

    Frame

    Weight

    Eyes

    Complexion

    Hair

    Joints

    Sleep Pattern

    Body Temperature

    Temperament

    Under Stress...

    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 of 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