Name *

First Name

Last Name

Do you have poor dream recall or nightmares? *

Yes

No

Do you have a reduced amount of head hair, eye-brows, or eyelashes, or do you have prematurely gray hair? *

Yes

No

When you were young, did you sunburn easily? Do you have fair or pale skin? *

Yes

No

Are you becoming more of a loner as you age? Do you avoid outside stress because it upsets your emotional balance? *

Yes

No

Have you been anxious, fearful, or felt a lot of inner tension since childhood but mostly hide theses inner feelings from others? *

Yes

No

Is it hard to clearly recall past events and people in your life? *

Yes

No

Do you have bouts of depression and/or nervous exhaustion? *

Yes

No

Do you have cluster headaches? *

Yes

No

Are your eyes sensitive to sunlight? *

Yes

No

Do you belong to an all-girl family, or have look-alike sisters? *

Yes

No

Do you get frequent colds or infections, or unexplained chills or fever? *

Yes

No

Do you dislike eating protein? Have you ever been a vegetarian? *

Yes

No

Did you reach puberty later than normal? *

Yes

No

Are there white spots/flecks on your fingernails, or do you have opaquely white or paper-thin nails? *

Yes

No

Are you prone to acne, eczema or psoriasis? *

Yes

No

Do you prefer the company of one or two close friends rather than a gathering of friends? *

Yes

No

Do you have stretch marks on your skin? *

Yes

No

Have you noticed a sweet smell (fruity odor) to your breath or sweat when ill or stressed? *

Yes

No

Do you have – or did you have, before braces – crowded upper front teeth? *

Yes

No

Do you prefer not to eat breakfast, or even experience light nausea in the morning? *

Yes

No

Do you tend to become dependent on one person whom you build your life around? *

Yes

No

Do you have a poor appetite, or a poor sense of smell or taste? *

Yes

No

Do you have any upper abdominal, splenic pain? As a child, did you get a “stitch” in your side when you ran? *

Yes

No

Do you tend to focus internally (on yourself) rather than on the external world? *

Yes

No

Do you frequently experience fatigue? *

Yes

No

Do you feel uncomfortable with strangers? *

Yes

No

Do your knees crack or ache? *

Yes

No

Do you overreact to tranquilizers, barbiturates, alcohol, or other drugs – that is, does a little produce a powerful response? *

Yes

No

Does it bother you to be seated in a restaurant in the middle of the room? *

Yes

No

Are you anemic? *

Yes

No

Do you have cold hands and/or feet? *

Yes

No

Are you easily upset (internally) by criticism? *

Yes

No

Do you have a tendency toward morning constipation? *

Yes

No

Do you have tingling sensations or muscle spasms in your legs or arms? *

Yes

No

Do changes in your routine (traveling, new situations) provide stress? *

Yes

No

Does your face sometimes look swollen while under a lot of stress? *

Yes

No