Name *

First Name

Last Name

Check all that apply.

The following screen is adapted from the work of Carl Pfeiffer and Joan Matthews Larson.

Do you tend to sneeze in bright sunlight?

Were you a shy and oversensitive teenager?

Can you make tears easily, and are never bothered by a lack of saliva or dry mouth?

Do you hear your pulse in your hed on the pillow at night?

Do you have frequent muscle cramps?

Do you have a high sensitivity to pain?

Do you find it easy to have orgasms with sex, and do you have a high libido?

Do you get headaches regularly?

Does your mind go blank at times?

Do you have seasonal allergies, such as hay fever?

Do you tend to be a light sleeper?

Do you need only five to seven hours of sleep each night?

Do you burn up foods rapidly?

Have you thought seriously of suicide?

Can you tolerate high doses of medication or drugs?

Are you addicted to drugs, alcohol, or sugar?

Are you a perfectionist or an obsessive, Type-A personality who feels driven?

Do boys predominate among your siblings or your father's siblings or other family members' children or siblings?

Is your skin sensitive (does it get itchy, rashy, red, hives)?

Have you noticed your mood goes down in April through June?