Developed by G. Roy Sumpter, Ph.D., N.M.D.


DIRECTIONS: If you can answer mostly YES to a question, check YES. If your answer is NO, check NO. If you are not sure, answer YES. Please answer all questions. Thank you.
Your Name:
Addictive Behavior: Alcohol/Substance Abuse
1. YesNo Have you lost time from work due to drinking or substance use
2. YesNo Has your drinking or substance use made your home life unhappy
3. YesNo Does your drinking or substance use make you careless of your family's welfare
4. YesNo Has drinking or substance use ever jeopardized your job or business
5. YesNo Do you drink or use substances to escape from worries or business
6. YesNo Do you drink or use substances alone
7. YesNo Have you ever had a complete loss memory as a result of drinking or substance use
8. YesNo Do you crave a drink or the use of a substance at a definite time daily
Addictive Behavior: Codependency Behaviors and Feelings
9. YesNo Impulsive
10. YesNo Often feel isolated and afraid of people, especially authority figures
11. YesNo Feel overly frightened of angry people and of personal criticisms
12. YesNo Often feel I am a victim in personal and career relationships
13. YesNo Confuse love with pity and tend to love people I can rescue
14. YesNo Find it hard to feel or express feelings, including feelings such as joy or happiness
15. YesNo Tend to be a reactor instead of an initiator
16. YesNo Leave bad relationships and form new ones that do not work either
17. YesNo Guess at what normal behavior is
18. YesNo Difficulty following project through to end
19. YesNo Lie when it would be just as easy to tell the truth
20. YesNo Have difficulty having fun or relaxing
21. YesNo Take yourself very seriously
22. YesNo Difficulty with intimate relationships
23. YesNo Usually feel different from other people
24. YesNo Super responsible or super irresponsible
25. YesNo Extremely loyal even when loyalty is undeserved
26. YesNo Have been physically abused
27. YesNo Have been emotional abused
28. YesNo Stay busy so I do not have to think about things
29. YesNo Tell myself that things will be better tomorrow
30. YesNo Pretend circumstances are not as bad as they are
31. YesNo Think and feel responsible for other people
32. YesNo Feel bored, empty, and worthless if you do not have a crisis, a problem to solve, or
Addictive Behavior: Partner's Disrespect Toward You
33. YesNo Spouse/significant other assumes right to control how you live and behave
34. YesNo Given up important activities in order keep spouse/significant other happy
35. YesNo Spouse/significant other devalues your opinions, feelings, accomplishments
36. YesNo Spouse/significant other yells, threatens, withdraws into angry silence when displeased
37. YesNo Walk on eggs, rehearsing what you will say so as not set him/her off
38. YesNo Spouse/significant other bewilders you by switching from charm to rage
39. YesNo Often feel confused, off-balance or inadequate
40. YesNo Spouse/significant other extremely jealous and possessive
41. YesNo Spouse/significant other blame you for everything that goes wrong
42. YesNo From February through May (Trees)
43. YesNo From May through July (Grasses)
44. YesNo July (Pigweed)
45. YesNo From August through first frost (Ragweed)
46. YesNo When first snap of Autumn comes
47. YesNo In the evening
48. YesNo Awaken 1 to 2 hours after going to bed?
49. YesNo Flares with thunderstorms
50. YesNo Worse immediately at bedtime
51. YesNo Worse from sunrise to sunset
52. YesNo Early hours of the morning
53. YesNo Last a few minutes
54. YesNo Last several hours
55. YesNo Last several days
56. YesNo Last whole season
57. YesNo Last the whole year
58. YesNo Exposed clothing stores, soap aisles, pumping gas, perfumes
59. YesNo When first open folded newspaper
60. YesNo During prolong periods of damp weather
61. YesNo When around where grass being mowed or weeds cut
62. YesNo When going into old damp house, damp basement
63. YesNo Enter closet stored old shoes, luggage, leather goods
64. YesNo If eat cheese, mushrooms, cantaloupe, drink beer or wine
65. YesNo Aversion to tobacco smoke
Anger, Sense of
66. YesNo Crankiness
67. YesNo Experience sudden/frequent mood swings, moodiness
68. YesNo You are impatient
69. YesNo Afraid of your own anger
70. YesNo Experience sickness or other ailments from being angry
71. YesNo Discontented
72. YesNo Have a bad temper
73. YesNo Have to be on guard even with friends
74. YesNo Easily upset or irritated
75. YesNo Little annoyances get on your nerves and make you angry
76. YesNo Makes you angry to have anyone tell you what to do
77. YesNo Anger flares up if you cannot have what you want right away
78. YesNo Inappropriate anger and/or crying
79. YesNo Experience frequent agitation
80. YesNo Quarrelsome and/or belligerent
81. YesNo Often sullen
82. YesNo Angry when contradicted
83. YesNo Obstinate
84. YesNo Often irritable or peevish, never satisfied
Anxiety, Sense of
85. YesNo Tend to imagine all of the worst possible things that could happen in a situation
86. YesNo Will relive in your mind the crisis over and over again even though the crisis may be
87. YesNo Tend to make mountains out of mole hills
88. YesNo Find yourself continually dwelling on the past
89. YesNo Do you find yourself talking too much
90. YesNo Every little thing gets on your nerves and wears you out
91. YesNo You are suspicious of others
92. YesNo Worrying about compatibility within the family
93. YesNo Worrying about my relationship with my spouse's/lover's parents
94. YesNo Worry about religion
95. YesNo Worrying about the amount and quality of your social life
96. YesNo Worry about drug/alcohol problems within your family
97. YesNo Worrying about the chronic health or mental health problems of yourself or your family
98. YesNo Feel anxious about problems and people
99. YesNo Worry continually gets you down, apprehensive
100. YesNo Anxiety about the future
101. YesNo Over sensitive to noise so that every sound causes you anxiety
102. YesNo You have a more serious appearance
103. YesNo Do you have a fear of certain objects or situations (such as snakes or elevators)
104. YesNo Become anxious when you leave home or familiar surroundings
105. YesNo Afraid of being in a crowd
106. YesNo Fear of being alone
Cardiovascular System
107. YesNo History of high cholesterol
108. YesNo Heart pounds or feel jittery
109. YesNo Ever had a cerebral vascular accident, (stroke)
110. YesNo Heart often races, rapid beating over 100
111. YesNo Get short of breath walking up hill or hurrying on level ground (I)
112. YesNo Get short breath walking normal pace on level ground (II)
113. YesNo Get short of breath requiring rest, while walking at normal pace, level ground (III)
114. YesNo Slow pulse, below 60
115. YesNo Low blood pressure
116. YesNo High blood pressure
117. YesNo Does your heart seem to miss beats or have extra beats
118. YesNo Have swelling of feet or ankles
119. YesNo Cold hands or feet even in warm weather, cold intolerance
120. YesNo Bruise easily, black and blue spots
121. YesNo Feeling pain or tightness in chest, angina pectoris
122. YesNo Noise in head or ringing in ears
123. YesNo Varicose veins or phlebitis
124. YesNo Attacks of weakness and pain in legs brought on by walking
Depression, Sense of
125. YesNo Considered a nervous person, restless
126. YesNo Are you often inattentive to dress or grooming
127. YesNo Often experience grief
128. YesNo Sense of sadness or depression periodically or in cycles
129. YesNo Find it difficult to feel close to people
130. YesNo Do you prefer to be alone
131. YesNo Are you frequently disappointed
132. YesNo Usually feel unhappy and depressed, sadness
133. YesNo Cry often
134. YesNo Have a sense of being overloaded or overwhelmed
135. YesNo Often wish you were away from it all or dead
136. YesNo Depression accompanied with being emotionally upset
137. YesNo Feelings of agitation with mental or physical collapse
138. YesNo Feelings of worthlessness or self reproach
139. YesNo Find yourself indifferent, losing interest in everyday activities
140. YesNo Lethargy, lassitude
141. YesNo Have little hope of escaping from problems or situation that make me uncomfortable,
142. YesNo Look for happiness outside of yourself i.e. from others or things
Digestion and Eating Habits: Digestion
143. YesNo Crave breads
144. YesNo Crave salt/salty things
145. YesNo Weight gain or loss without dieting
146. YesNo Experience pain around stomach after eating fatty foods
147. YesNo Have a partial plate or dentures
148. YesNo Heartburn
149. YesNo Often sick to stomach/nausea, gets upset easily
150. YesNo Suffer from indigestion
151. YesNo Suffer stomach pain/cramping, irritation
152. YesNo Ever had piles or hemorrhoids
153. YesNo Appetite often poor or reduce, lacking
154. YesNo Belching, burping, gas
155. YesNo Abdominal bloating
156. YesNo Excessive abdominal gas, flatulence
157. YesNo Abdominal distress, cramping
158. YesNo Bad breath
159. YesNo Gall bladder trouble, pain right side just below rib cage
160. YesNo Ulcers, stomach or peptic: Pain, brought on by food and relieved by antacids. Pain
161. YesNo Ulcers, duodenal: Pain begins 2-3 hours after a meal or awakens you at night.
162. YesNo Do NOT have a bowel movement EVERY day
163. YesNo Constipation or difficult bowel movement
164. YesNo Loose bowel movements or diarrhea
165. YesNo Diarrhea alternating with constipation
166. YesNo Irritable or spastic colon
167. YesNo Ulcerative colitis, bloody or mucous discharge
168. YesNo Increased thirst
169. YesNo Decreased sense of taste
170. YesNo Excessive salivation
171. YesNo Empty feeling in your stomach
172. YesNo Cramping pain in lower abdomen relieved with passing gas or stool
Digestion and Eating Habits: Eating Disorders
173. YesNo Consume large quantities of high caloric foods
174. YesNo Very concerned about becoming thin
175. YesNo Tend to maintain near normal weight
176. YesNo Tend to be overweight
177. YesNo Uncontrollable appetite
178. YesNo Unexplained increase in weight
179. YesNo Become anxious prior to eating
180. YesNo Am terrified about being overweight
181. YesNo Avoid eating when I am hungry
182. YesNo Cut my food into small pieces
183. YesNo Feel others would prefer if I ate more
184. YesNo Vomit after I have eaten
185. YesNo Feel extremely guilty after eating
186. YesNo Exercise strenuously to bum off calories
187. YesNo Weigh myself several times a day
188. YesNo Eat the same foods day after day
189. YesNo Take laxatives
190. YesNo Always seem to be on a diet
191. YesNo Feel food controls my life
192. YesNo Have lost at least 25 % of original body weight
193. YesNo Alternate between periods of fasting and bingeing
194. YesNo Fear changes in body appearance
195. YesNo Other people think I am too thin
196. YesNo Do you eat in secret
197. YesNo Feel you have lost control over eating
198. YesNo Spent a lot of time thinking about food
199. YesNo Ever eat to the point of being in pain
200. YesNo Does you weight alternate during bingeing and fasting
201. YesNo Hearing loss or hard of hearing
202. YesNo Hear better with glasses on
203. YesNo Frequent ear infections/ problems
204. YesNo Drainage or discharge
205. YesNo Itching deep in ears
206. YesNo Sensation of fullness or pressure in the ear
207. YesNo Sensitivity to noise
208. YesNo Auditory hallucinations
209. YesNo Blurring of or erratic vision
210. YesNo Spots in front of eyes
211. YesNo Ever see zig-zag patterns in field of vision
212. YesNo Ever experience double vision
213. YesNo Eyes get tired easily
214. YesNo Poor color vision
215. YesNo Poor vision in dim light
216. YesNo Sensitive to light
217. YesNo Tunnel vision or reduction in visual field
218. YesNo Eyes often red or inflamed, bloodshot
219. YesNo Eyes red with watery discharge, itching
220. YesNo Itch with watery discharge but eyes are not red
221. YesNo Irritation, inflammation or reddening of eyelids
222. YesNo Often have eye strain or discomfort
223. YesNo Itching outer corner of eye
224. YesNo Excessive tearing
225. YesNo Itching inner corner of eye
226. YesNo Itching inner corner of eye with thick scaly patches
227. YesNo Puffiness under eyes or of lids
228. YesNo Long silky eye lashes
229. YesNo Bulging, protruding eyes
230. YesNo Often have styes
231. YesNo Poor or reduced tear production, eyes dry
232. YesNo Dark circles under eyes
Fatigue, Degree of
233. YesNo Often have spells of complete exhaustion/fatigue
234. YesNo Listlessness/ lethargic
235. YesNo Usually get up tired but get better as day goes on
236. YesNo Usually get up refreshed but tire as day goes on
237. YesNo Inability to maintain usual routines
238. YesNo Constantly too tired and exhausted to enjoy life
239. YesNo Every little effort wears you out, feeling of being drained
240. YesNo Red, tender swelling of soft tissue surrounding nail
241. YesNo Poor nail growth
242. YesNo Heavy ridges running from base to tip
243. YesNo Severe ridges running across the nail
244. YesNo Weak, brittle or peeling nails
245. YesNo White spots
246. YesNo Spoon or saucer shaped, or flattened nails
247. YesNo White bands running across nail
248. YesNo Clubbing, excessive curvature from base to tip
249. YesNo Yellow-green, thickened, excessive curvature from side to side
250. YesNo Red half moons at base of nail
251. YesNo Light blue half moons at base of nail
252. YesNo Paired narrow pale bands running across nail
253. YesNo Brownish discoloration at edge of nails, changes in shape, thickness
254. YesNo Splitting, chipping, cracking of nail
255. YesNo Opaque or cloudy, soft nails
256. YesNo Pinhead-size depression, yellow-white where tissue/nail separate
257. YesNo Bluish nail
258. YesNo Yellow nail
259. YesNo New brown stripe running base to tip which grows with nail
260. YesNo Green-black discoloration at base of nail
261. YesNo Soft white islands on nail surface that may spread to become large patches
262. YesNo White or yellow discoloration, considerable disfiguration and possible separation of nail
Genitourinary System and Feelings: Female
263. YesNo Ever had an abnormal PAP smear, cervical dysplasia
264. YesNo Fibrocystic breasts: Lumps, various sizes, sensitive, soft, freely moveable
265. YesNo Frequent vaginal discharge or vaginitis x 3 or more
266. YesNo Persistent vaginal burning or itching
267. YesNo Vaginal irritation with while-cheesy discharge
268. YesNo Greenish-yellow frothy vaginal discharge with irritation and soreness
269. YesNo Menses often clotted
270. YesNo Menstrual flow usually prolonged
271. YesNo Menstrual flow usually scanty
272. YesNo Do you often experience pain in your ovary
273. YesNo Have stopped having menstrual cycle, menopause
274. YesNo Have constant severe hot flashes and sweats
275. YesNo Unable or failure to reach orgasm
276. YesNo Reduction in frequency of menstruation, longer in between
277. YesNo Painful menstrual flow
278. YesNo Menses never at the same time
279. YesNo Heavy menstrual flows
280. YesNo Often have a menstrual flow between my normal periods, metarrahagia
281. YesNo Pregnant 2 or more times
282. YesNo Taken birth control pills more than one year
Genitourinary System and Feelings: Female: Premenstrual Syndrome
283. YesNo Nervous tension
284. YesNo Irritability
285. YesNo Mood swings
286. YesNo Anxiety
287. YesNo Increased appetite (binge eating)
288. YesNo Headaches
289. YesNo Fatigue, episode of
290. YesNo Dizziness or fainting spells
291. YesNo Heart pounding, palpitations
292. YesNo Craving for sweets
293. YesNo Depression
294. YesNo Crying
295. YesNo Forgetfulness
296. YesNo Confusion, in coherence
297. YesNo Insomnia, sleep disturbances
298. YesNo Withdrawal
299. YesNo Lethargy
300. YesNo Difficulty saying what you mean
301. YesNo Fluid retention
302. YesNo Weight gain greater than 3 pounds
303. YesNo Swelling extremities or face
304. YesNo Breast tenderness
305. YesNo Abdominal bloating and discomfort
306. YesNo Aches and pains
307. YesNo Reduced pain threshold
Genitourinary System and Feelings: General
308. YesNo Lingering mistrust or anger toward opposite sex
309. YesNo Tendency toward bladder infections
310. YesNo Urine has offensive odor
311. YesNo Get up frequently during the night to urinate
312. YesNo During the day, usually urinate frequently
313. YesNo Dribbling of urine whenever cough, sneeze, or laugh
314. YesNo Lose control of your bowels
315. YesNo Infertility, inability to conceive
316. YesNo Problems with decreased sex drive
317. YesNo Kidney stones
318. YesNo Disinterested in your own sexuality
319. YesNo Aversion to sexual intercourse
320. YesNo Have excessive sexual desire that cannot be satisfied
321. YesNo Painful intercourse
322. YesNo Aversion to or fear of sexual intimacy
323. YesNo Have been sexually abused or molested
324. YesNo Small single or grouped blister-like bumps on skin near sex organs. Rupture leaving
325. YesNo Increased or excessive menstrual flow
Genitourinary System and Feelings: Male
326. YesNo Premature ejaculation during sexual intercourse
327. YesNo Trouble starting your stream when urinating or urine dribbles
328. YesNo Inability to get or maintain an erection
329. YesNo Sex organs have gotten smaller
330. YesNo Difficulty with reaching a climax
331. YesNo Burning pain or tingling when urinating
332. YesNo Loss of hair above forehead and at crown of head
333. YesNo Thinning of scalp hair
334. YesNo Dandruff, redness, scaling, itching hair
335. YesNo Brittle hair
336. YesNo Oily hair
337. YesNo Decreased amount of hair under arms and in pubic area
338. YesNo Prematurely graying
339. YesNo Scalp hair fine in texture, oily, abundant
340. YesNo Increase in body hair over trunk, extremities or face
341. YesNo Dry, coarse hair, lacking luster and sheen
Headaches: Cluster
342. YesNo Pain usually on one side only
343. YesNo Usually involves eye, forehead, or temple and then spreads over the affected side
344. YesNo Each attack lasts short period but may be 1 - 8 /day for weeks
345. YesNo Sharp, boring/burning pain: hot poker boring through eye, excruciating
346. YesNo Headaches feel as if a nail were driven into your head
347. YesNo Often occurs at night awakening you with excruciating pain
348. YesNo Drooping, swelling and redness of eyelid
349. YesNo White of eye red and often with tearing
Headaches: Migraine
350. YesNo Throbbing or pulsating head pain
351. YesNo Pain usually beings on one side only but then often spreads to other side
352. YesNo Nausea often occurs with headache
353. YesNo Sensitivity to light and sounds often occurs with headache
354. YesNo Slow onset but may last for days
355. YesNo Loss or blurred field of vision (often zig-zag pattern)
356. YesNo Bursting headache as though your head would explode
357. YesNo May be preceded by an aura of such things as numbness, weakness, dizziness, etc.
Headaches: Sinus
358. YesNo Pain worse by bending over, jostling, straining, coughing
359. YesNo Pain located in facial area or forehead near eyebrows
360. YesNo Postnasal drip causes irritation and inflammation of throat
361. YesNo Headache worse in morning
Headaches: Tension
362. YesNo Dull steady, non-pulsating pain, pressure
363. YesNo Pain usually in back of head or from front to back
364. YesNo Pain usually occurs on both sides of head
365. YesNo Often begins with stiff neck and sore shoulder muscles
366. YesNo Tightness, as though head were being compressed inward
Illness, Frequency of
367. YesNo Cuts usually take long time to heal
368. YesNo Small cuts fester and become infected easily
369. YesNo Aggravated in dry weather (low humidity, high temperature)
370. YesNo Still suffering from ill effects surgical procedure (an operation
371. YesNo Worse in wet weather
372. YesNo Do you have enlarged glands in neck, armpits, groin or legs
373. YesNo Do you lack any symptoms of illness, even though you know you are not well
374. YesNo Signs/symptoms of your discomfort or disease always changing
375. YesNo Suffer ill effects from being cold, cold air or wind
376. YesNo Suffer ill effects from being angry
377. YesNo Frequent colds or bouts with the flu
378. YesNo Often in poor health
379. YesNo Worry about your health
380. YesNo Weakness after colds or flu, poor recuperation
381. YesNo Taken antibiotics 2 months or longer or 4 shorter treatments in one year
382. YesNo Taken antibiotics even for single treatment
383. YesNo Taken prednisone/ cortisone-type anti-inflammatory drugs for two weeks or more
384. YesNo Fear of death
385. YesNo Vague aches and pains
Inadequacy, Sense of
386. YesNo Get guilt feelings when I stand up for my self instead of giving into others
387. YesNo Have a low sense of personal self-esteem
388. YesNo Judge yourself without mercy
389. YesNo Constantly seek approval and affirmation while loosing my own identity in the process
390. YesNo Afraid to let yourself be who you really are
391. YesNo Tolerate abuse to keep people loving you
392. YesNo Came from a home where emotional needs where not met
393. YesNo Terrified of abandonment, would do anything to keep a relationship
394. YesNo Willing to take more than 50% of the responsibility, guilt, and/or blame
395. YesNo Believe you do not deserve happiness, but must earn the right to be happy
396. YesNo Find yourself saying Yes when you mean No
397. YesNo Try to please others instead of yourself
398. YesNo Have difficulty accepting compliments or praise
399. YesNo Never really satisfied with your performance
400. YesNo Think you are not quite good enough
401. YesNo Feel guilty about spending money on yourself or doing unnecessary or
402. YesNo Afraid of making a mistake
403. YesNo Difficulty in making decisions
404. YesNo Try to prove you are good enough for other people
405. YesNo Do not say what you mean
406. YesNo Ask for what you want and need indirectly
407. YesNo Do not trust your feelings
408. YesNo Do not trust your decisions
409. YesNo Are you an insecure person
410. YesNo Perspire or tremble a lot during examinations or questioning
411. YesNo Thinking gets mixed up when have to do things quickly
412. YesNo Must do things very slowly order do them without mistakes
413. YesNo Considered a clumsy person, accident prone
414. YesNo Feel inferior in intelligence, personality, or appearance
415. YesNo Often overly self-conscious or shy when among strangers
416. YesNo Whenever something goes wrong, you tend to blame yourself
417. YesNo Feel inadequate in my present position or job
418. YesNo You not comfortable or at ease around superiors
419. YesNo When you do not succeed, tend to let it depress you more than it should
420. YesNo Are not at ease when around members of the opposite sex
421. YesNo Dry cough
422. YesNo Cough producing phlegm or mucus
423. YesNo Shortness of breath
424. YesNo Feel as though you are going to suffocate, air hunger
425. YesNo Trouble with constant cough
426. YesNo Irregular or rapid breathing
427. YesNo Difficult or labored breathing
428. YesNo Pain, tightness or constriction in chest not related to heart
429. YesNo Wheezing
Mental Function
430. YesNo Find yourself becoming forgetful or indecisive because you have too much on
431. YesNo Mental restlessness
432. YesNo Troubling thoughts continually coming to mind
433. YesNo Difficulty recalling things that happened in the past
434. YesNo Do you find yourself forgetting what you were about to do
435. YesNo Do you find yourself using the wrong words, terms that do not describe what youreally trying to say
436. YesNo Difficulty in concentrating
437. YesNo Unusually forgetful
438. YesNo Confusion or disorientation
439. YesNo Feel spacey or unreal
440. YesNo Poor memory for day to day, recent, or immediate things
441. YesNo Dullness, sluggishness, difficulty in thinking and comprehending
442. YesNo Learning disability
443. YesNo Disorientation
Mouth and Throat
444. YesNo Metallic taste in mouth
445. YesNo Hoarseness, laryngitis, voice coarse
446. YesNo Dry mouth
447. YesNo Difficulty in swallowing, lump sensation
448. YesNo Need to clear mucus from throat, especially in morning
449. YesNo Frequent sore throats
450. YesNo Itching at top of mouth
451. YesNo Itching back of throat
452. YesNo Bleeding or sore gums
453. YesNo Grinding or clenching of teeth especially while asleep
454. YesNo Tendency to form cavities (cavities)
455. YesNo Canker sores, tip or sides tongue and inside mouth
456. YesNo Cold sores, fever blisters on lips and around mouth
457. YesNo Yellow tongue with red edges
458. YesNo Inflamed or swollen tongue
459. YesNo Purple color to tongue
460. YesNo Tongue smooth tip and edges, shiny red
461. YesNo Black tongue, looks like growing short hairs
462. YesNo Redden elevations on tongue suggest cobblestone strawberry
463. YesNo Tongue looks like a map
464. YesNo Tongue feels thick, large, awkward
Musculoskeletal Systems
465. YesNo Muscle tenseness, bracing
466. YesNo Muscles score to touch, painful
467. YesNo Joints often painfully swollen
468. YesNo Muscles and joints constantly feel stiff
469. YesNo Feet often sore or painful
470. YesNo Back pain or backache
471. YesNo Get cramps, muscle twitches at night, restless legs
472. YesNo General weakness of muscles
473. YesNo Wandering muscle or join pains
474. YesNo Calf cramps
475. YesNo Drawing sensation back of neck
476. YesNo Fine tremor, shaking hands
477. YesNo Muscular restlessness, excessive movement, fidgety
478. YesNo Bone pain
479. YesNo Brittle bones, easily broken, frequent fractures
480. YesNo Poor muscle coordination, walking difficulty
481. YesNo Muscle wasting
482. YesNo Poor or stunted growth, late developing
483. YesNo Muscle spasms or cramps
484. YesNo Joint pain
485. YesNo Muscle pain
486. YesNo Premature aging
487. YesNo Weakness of hand muscles on thumb half of hand
Nervous System
488. YesNo Get dizzy while walking or moving
489. YesNo Get dizzy on rising or getting up
490. YesNo Get dizzy when stooping or bending over
491. YesNo Frequently feel faint, lightheaded
492. YesNo Frequent numbness or tingling any part of body
493. YesNo Change in sensation in thumb and next two fingers
494. YesNo Twitching of face, or any other part of the body
495. YesNo Wet the bed as a young child
496. YesNo Wet bed after the age of 8
497. YesNo Ever had a convulsion or seizure
498. YesNo Restless behavior, hyperactivity
499. YesNo Excitability
500. YesNo Excessive sweating, perspiration
501. YesNo Sensitive to external impressions: light, noise, odors, touch
502. YesNo Frequently sigh
503. YesNo Burning sensation on any part of body
504. YesNo Especially sensitive to odors
505. YesNo Nose frequently itches
506. YesNo Frequent nose bleeds
507. YesNo Difficulty breathing through your nose Helped By: Homeopathics: Lyc, Nux-v
508. YesNo Sinus trouble
509. YesNo Repetitious sneezing
510. YesNo Running watery nose, sniffling
511. YesNo Thick post nasal drip down throat
512. YesNo Wiping nose with upward movement rather than from side to side
513. YesNo Lining of nose bluish/gray with swelling
514. YesNo Thick gummy nasal discharge
515. YesNo Lining of nose red and irritated
516. YesNo Decreased sense of smell
517. YesNo Of limited duration
518. YesNo Constant
519. YesNo Periodically, follows a pattern
520. YesNo Occasionally
521. YesNo Mild
522. YesNo Discomforting
523. YesNo Distressing
524. YesNo Horrible
525. YesNo Excruciating
526. YesNo Comes on suddenly
527. YesNo Stops suddenly
528. YesNo Symptoms ever changing
529. YesNo Shifts from one part to another
530. YesNo Aggravated by consolation
531. YesNo Aggravated by damp weather
532. YesNo Right sided
533. YesNo Left sided
534. YesNo Sleeping aggravates
535. YesNo Sleeping helps
536. YesNo Standing aggravates
537. YesNo Standing helps
538. YesNo Warmth aggravates
539. YesNo Better in open air
540. YesNo Open air aggravates
541. YesNo Cold aggravates
542. YesNo Lying down aggravates
543. YesNo Motion aggravates
544. YesNo Motion helps
545. YesNo Paralytic
546. YesNo As if scraped
547. YesNo Twisting, wringing
548. YesNo Wandering
549. YesNo Throbbing
550. YesNo Jumping
551. YesNo Shooting
552. YesNo Boring
553. YesNo Stabbing
554. YesNo Sharp
555. YesNo Cutting
556. YesNo Stitching
557. YesNo Biting
558. YesNo Pinching
559. YesNo Pressing
560. YesNo Gnawing
561. YesNo Cramping
562. YesNo Constricting
563. YesNo Burning
564. YesNo Tearing
565. YesNo Dull
566. YesNo Sore, bruised
567. YesNo As if a nail were driven into your body
568. YesNo Vice-like, gripping
569. YesNo Hurting
570. YesNo Aching
571. YesNo Tender
572. YesNo Tiring
573. YesNo Exhausting
574. YesNo Sickening
575. YesNo Fearful
576. YesNo Annoying
577. YesNo Troublesome
578. YesNo Miserable
579. YesNo Intense
580. YesNo Unbearable
581. YesNo Spreading
582. YesNo Radiating
583. YesNo Penetrating
584. YesNo Piercing
585. YesNo Tight
586. YesNo Drawing
587. YesNo Squeezing
588. YesNo Nagging
589. YesNo Nauseating
590. YesNo Agonizing
Sensitivity (Touchiness), Sense of
591. YesNo Cry easily
592. YesNo Extremely shy or sensitive
593. YesNo Feelings easily hurt, offend easily
594. YesNo Criticism usually upsets you
595. YesNo Considered a touchy person
596. YesNo Do people usually misunderstand you
597. YesNo Skin dirty-looking even though it is clean
598. YesNo Tendency to have corns/callouses
599. YesNo Have sebaceous cysts (oily fatty cyst usually forming alump on head, shoulder, or back)
600. YesNo Old scars (from injury or surgery) that itch or stick or otherwise bother you
601. YesNo Dry, rough, cracked skin
602. YesNo Gooseflesh, goosepimples, bumpy skin, cold chills
603. YesNo Tiny fatty deposits like whiteheads
604. YesNo Oily skin
605. YesNo Dry, scaly skin
606. YesNo Psoriasis: Pink or red elevated patches of skin covered by dry, silvery scales
607. YesNo Seborrhea: Dry, yellowish scales on skin which may be
608. YesNo Acne
609. YesNo Patches of skin without color
610. YesNo Skin pigmentation, brown spots especially creases and pressure areas
611. YesNo Rashes
612. YesNo Itching skin
613. YesNo Itching middle of shoulder blade
614. YesNo Itching and/or redness around anus
615. YesNo Eczema: rough, dry, scaly, redness, swelling, small blisters, often itches
616. YesNo Eczema bend arm, behind knee, forearm, lower legs, cheeks
617. YesNo Eczema elbow, knee, rashes outside surfaces arms and legs
618. YesNo Pink/purple streaks, spider-like blood vessels
619. YesNo Red, itchy rash from sunlight esp back of hands
620. YesNo Blushing/ blotching, hives
621. YesNo Sensation insects crawling over skin
622. YesNo Persistent athlete's foot or fungal infections of skin or nails
623. YesNo Small purplish-red non raised spots, pinpoint hemorrhages
624. YesNo Taken tetracycline or other antibiotics for acne one month or longer
625. YesNo Boils
626. YesNo Peeling skin
627. YesNo Skin thin, paper like
628. YesNo All tone gone out of skin
629. YesNo Poorly defined, red, gray, tan, or flesh colored patches that feel rough to touch
630. YesNo Mole with irregular margin or uneven surface or irregular coloring or bleeding
631. YesNo Numerous small, pointed pimples on upper arm, buttocks, and/or thigh
632. YesNo Trouble falling asleep
633. YesNo Cannot fall asleep because cannot stop thinking
634. YesNo Cannot fall asleep because of physical restlessness
635. YesNo Cannot remember your dreams
636. YesNo Extremely loud snoring
637. YesNo Wake up during sleep
638. YesNo Waking up too early in the morning
639. YesNo Dread going to bed
640. YesNo Sleepy during the day
641. YesNo Gasping for air during sleep, chocking
642. YesNo Morning fatigue
643. YesNo Legs jerk during sleep
644. YesNo Cramps, pain, crawling sensation in legs while lying in bed
645. YesNo Involuntarily falling asleep during the day
646. YesNo Muscle become paralyzed briefly during the day
647. YesNo Hallucinations at onset of sleep
648. YesNo Sleep does not seem refreshing
649. YesNo Nightmares or nigh terrors
650. YesNo Sudden frightening awakenings with fear and physical discomfort
651. YesNo Speech is absent or slow and monotonous
652. YesNo Rapid speech, speech faster than normal
653. YesNo Slurring of speech, thick speech
654. YesNo Stammering or stuttering
655. YesNo Difficulty in pronouncing words
Stress: Causes of
656. YesNo Encounter noise pollution or excess distractions on the job
657. YesNo Feeling stress from heavy labor on the job, or dangerous or poor working conditions
658. YesNo You commute to work more than 1 /2 hour each way
659. YesNo Feel unstimulated by your job
660. YesNo Feel loneliness or lack of affection and support in your life
661. YesNo Feeling bored or trapped in your home situation
662. YesNo Lose interest in your daily activities
663. YesNo Find yourself becoming restless during your daily routine
664. YesNo Wish life were more exciting
665. YesNo Feel your usual activities are not challenging enough
666. YesNo Find yourself daydreaming during your work
667. YesNo Have recently moved to a new community
668. YesNo Being held responsible without having real control
669. YesNo Feeling underpaid, under compensated, or unappreciated
670. YesNo Feel stifled or held back in your personal or professional life
671. YesNo Feeling pressures at work from one or more superiors
672. YesNo Having personality clashes with superiors
673. YesNo Criticism directed at you/your department from inside the organization
674. YesNo Feeling unsatisfied over my present marital situation
675. YesNo Feeling unsatisfied over my present sex life
676. YesNo Feeling frustrated because of my children's behavior
677. YesNo Having arguments or discord with spouse/lover
678. YesNo Getting criticism from my spouse/lover
679. YesNo Getting criticism from my extended family, including ex-spouses and in-laws
680. YesNo Feel as though your life needs guidance or direction
681. YesNo Find yourself feeling as if you are in a rut
682. YesNo Find yourself disillusioned
683. YesNo Find yourself frustrated
684. YesNo Find yourself disappointed
685. YesNo Find yourself upset because things have not gone according to plan
686. YesNo Having financial pressures
687. YesNo You have retired
688. YesNo Your spouse has retired
689. YesNo Having legal difficulties
690. YesNo Feeling I do not get enough time to myself
691. YesNo Find yourself with insufficient time to do things you really enjoy
692. YesNo Wish you had more support/assistance
693. YesNo Lack sufficient time to effectively complete your work
694. YesNo Having difficulty falling asleep because you have too much on your mind
695. YesNo Feel people simply expect too much from you
696. YesNo Feel overwhelmed
697. YesNo Feel you have too much responsibility for one person
698. YesNo Feel exhausted at the end of the day
699. YesNo Have many projects going on at one time
700. YesNo You are constantly troubled by incomplete work
701. YesNo You are responsible for caring for an ailing parent or in-law
702. YesNo Try to avoid situations where you find yourself feeling helpless or hopeless
703. YesNo Try to avoid situations which seems out of your control
704. YesNo Find yourself needing to control the people around you
705. YesNo Find yourself needing to control your environment
706. YesNo Feel more comfortable having your life highly structured
707. YesNo You need to feel secure
708. YesNo Do many things yourself rather than delegate the responsibility
709. YesNo Definitely hard driving and competitive
710. YesNo Consider self more responsible than the average person
711. YesNo Give much more effort than the average person
712. YesNo Hurry more than the average person
713. YesNo Consider yourself much more precise than average person
714. YesNo Approach life much more seriously than the average person
715. YesNo Employed in a job which stirs you into action
716. YesNo Everyday life filled with challenges to be met
717. YesNo Frequently set deadlines for yourself at home
718. YesNo Keep two projects moving forward regularly
719. YesNo Would prefer a promotion to an increase in pay
720. YesNo Income has increased considerable in the past 3 years
721. YesNo Present job has more responsibility than job of 10 years ago
722. YesNo Often have trouble finding time for a haircut or hair appointment
723. YesNo Eat more rapidly than most people
724. YesNo Frequently hurry a speaker to the point
725. YesNo Frequently put words into a speaker's mouth
726. YesNo Often inattentive to lengthy comments by others
Stress: Preventing Measures
727. YesNo Eat at least one hot, balanced meal a day
728. YesNo Sleep seven to eight hours at least four nights a week
729. YesNo Give and receive affection regularly
730. YesNo Have at least one relative within 50 miles on whom can rely
731. YesNo Exercise to point perspiration at least twice a week
732. YesNo Smoke more than 10 cigarettes a day. (If do not smoke, answer No)
733. YesNo Consume fewer than five alcoholic drinks week
734. YesNo Am appropriate weight for my height
735. YesNo Have income adequate to meet basic expenses
736. YesNo Get strength from my religious beliefs
737. YesNo Regularly attend a club or social activities
738. YesNo Have network friends and acquaintances
739. YesNo Have one or more friends to confide in about personal matters
740. YesNo Am in good health
741. YesNo Able to speak openly my feelings when angry or worried
742. YesNo Communicate with people I live with about chores, money, etc
743. YesNo Do something for fun at least once a week
744. YesNo Able to organize my time effectively
745. YesNo Drink fewer than three cups caffeine daily
746. YesNo Take quiet time for myself each day
Sugar: Adrenal Hormonal Response
747. YesNo Hunger between meals
748. YesNo Get shaky if hungry
749. YesNo Faintness if meals delayed
750. YesNo Heart pounds if meals missed or delayed
751. YesNo Chronic nervous exhaustion
752. YesNo Inner trembling or restlessness
753. YesNo Overall weakness
754. YesNo Sweating if meals missed or delayed
Sugar: General
755. YesNo Overeating of sweets upsets system
756. YesNo Awaken after few hours sleep, hard to get back to sleep
757. YesNo Abnormal craving for sweets or snacks
Sugar: Lack of Sugar to the Brain
758. YesNo Slowness in thinking and concentration relieved by eating
759. YesNo Irritable before meals
760. YesNo Fatigue relieved by eating
761. YesNo Afternoon headaches
762. YesNo Moods or depression, blues, melancholy; personality changes
763. YesNo Sleepy after meals, drowsiness
764. YesNo Lack muscle coordination, clumsiness, if miss meal
765. YesNo Motor weakness
766. YesNo Speech difficulties
767. YesNo Visual disturbances