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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