| Your Name: |
Your e-mail: |
Characteristics
|
|
Never |
Mildly |
Somewhat |
Mostly |
Always |
| My mind is very restless/overactive |
yes |
yes |
yes |
yes |
yes |
| I am always formulating new ideas & love experimenting with them |
yes |
yes |
yes |
yes |
yes |
| I have frequent change of interest /I get bored of one project very soon |
yes |
yes |
yes |
yes |
yes |
| I speak quickly & am a very talkative |
yes |
yes |
yes |
yes |
yes |
| Under stress, I worry or become anxious/have weak memory |
yes |
yes |
yes |
yes |
yes |
| I have low requirement of sleep/insomniac |
yes |
yes |
yes |
yes |
yes |
| I am thin and am underweight |
yes |
yes |
yes |
yes |
yes |
| My diet is unpredictable; sometimes I am hungry & other times I have to force myself to eat. |
yes |
yes |
yes |
yes |
yes |
| Under stress or when traveling, I am likely to have constipation. |
yes |
yes |
yes |
yes |
yes |
| My digestion is irregular with gaseous distention & bizarre bowel movements |
yes |
yes |
yes |
yes |
yes |
| I have intolerance to cold/have cold hands & feet |
yes |
yes |
yes |
yes |
yes |
| My skin & hair are thin, dry or flaky |
yes |
yes |
yes |
yes |
yes |
| Total (V) |
|
