Constitution Evaluation Questionnaire Constitution Analysis Questionnaire Please choose your gender Male Female Group I- Your Look 1. Do you like being quiet but not talking? Never Rarely Sometimes Frequently Always 2. Does your face look gloomy or prone to speckles? Never Rarely Sometimes Frequently Always 3. Are you prone to dark circles around the eyes? Never Rarely Sometimes Frequently Always 4. Are your lips dim or darkish? Never Rarely Sometimes Frequently Always 5. Are your lips redder than the average? Never Rarely Sometimes Frequently Always 6. Are your skin or lips dry? Never Rarely Sometimes Frequently Always 7. Are your cheeks flushing or reddish? Never Rarely Sometimes Frequently Always 8. Are there any fine red lines on your cheeks? Never Rarely Sometimes Frequently Always 9. Is your abdomen plump and soft? Never Rarely Sometimes Frequently Always 10. Do you have an oily face? Never Rarely Sometimes Frequently Always 11. Is your upper eyelid slightly swelling? Never Rarely Sometimes Frequently Always 12. Do you feel oily on your face or nose? Never Rarely Sometimes Frequently Always 13. Are you prone to acne or boils? Never Rarely Sometimes Frequently Always 14. Do you get purple bruises under the skin? Never Rarely Sometimes Frequently Always 15. Is your skin prone to red marks when scratched? Never Rarely Sometimes Frequently Always Group II- Your Feeling 1. Are you energetic? Never Rarely Sometimes Frequently Always 2. Are you easy to get tired? Never Rarely Sometimes Frequently Always 3. Are you easily nervous or anxious? Never Rarely Sometimes Frequently Always 4. Are you sentimental? Never Rarely Sometimes Frequently Always 5. Are you easily scared or frightened? Never Rarely Sometimes Frequently Always 6. Is your voice low and weak? Never Rarely Sometimes Frequently Always 7. Do you feel gloomy and depressed? Never Rarely Sometimes Frequently Always 8. Do you feel bitterness or odor in your mouth? Never Rarely Sometimes Frequently Always 9. Do you feel dry eyes? Never Rarely Sometimes Frequently Always 10. Do you feel dry and want to drink water? Never Rarely Sometimes Frequently Always 11. Do you feel chest stuffiness or fullness in the abdomen? Never Rarely Sometimes Frequently Always 12. Does your body feel heavy? Never Rarely Sometimes Frequently Always 13. Do you feel hot in the hands and feet? Never Rarely Sometimes Frequently Always 14. Do you feel hot in the face? Never Rarely Sometimes Frequently Always 15. Do you sigh for no reason? Never Rarely Sometimes Frequently Always 16. Are you forgetful? Never Rarely Sometimes Frequently Always 17. Are you easy to catch a cold? Never Rarely Sometimes Frequently Always 18. Do you feel sticky in the mouth? Never Rarely Sometimes Frequently Always 19. Do you feel much phlegm in your throat? Never Rarely Sometimes Frequently Always 20. Is your tongue coating thick and greasy? Never Rarely Sometimes Frequently Always 21. Does your stool feel sticky or unfinished after the bowel movement? Never Rarely Sometimes Frequently Always 22. Do you feel cold in the stomach, back, waist, or knees? Never Rarely Sometimes Frequently Always 23. Do you feel any pain in the body? Never Rarely Sometimes Frequently Always 24. Do you feel any swelling pain in the side ribs or breast? Never Rarely Sometimes Frequently Always 25. Do you feel like any foreign body in the throat, that neither be coughed up nor swallowed? Never Rarely Sometimes Frequently Always 26. Do you fear cold and have to wear more than others? * Never Rarely Sometimes Frequently Always Group III- Your Discomfort No 1. Are you less tolerant to cold than average, like the chill in winter, low AC in summer? Never Rarely Sometimes Frequently Always 2. Can you adapt well to weather changes? Never Rarely Sometimes Frequently Always 3. Are you prone to shortness of breath or difficulty in catching breath? Never Rarely Sometimes Frequently Always 4. Are you easily nervous or flustered? Never Rarely Sometimes Frequently Always 5. Are you prone to insomnia? Never Rarely Sometimes Frequently Always 6. Are you prone to dizziness, especially when standing up? Never Rarely Sometimes Frequently Always 7. Are you prone to profuse sweating whenever you start exercising? Never Rarely Sometimes Frequently Always 8. Are your hands and feet cold? Never Rarely Sometimes Frequently Always 9. Do you feel uncomfortable or afraid of consuming cold foods? Never Rarely Sometimes Frequently Always 10. Are you prone to diarrhea after catching a cold or consuming cold food? Never Rarely Sometimes Frequently Always 11. Do you sneeze when not catching a cold? Never Rarely Sometimes Frequently Always 12. Do you have a stuffy and runny nose when not catching a cold? Never Rarely Sometimes Frequently Always 13. Do you cough during seasonal and temperature changes or because of peculiar smells? Never Rarely Sometimes Frequently Always 14. Do you have allergies, e.g., medicine, food, smell, pollen, and during the season or climate change? Never Rarely Sometimes Frequently Always 15. Are you prone to constipation or dry feces? Never Rarely Sometimes Frequently Always 16. Do you feel hot in the urinary tract while urinating, and is your urine deep in color? Never Rarely Sometimes Frequently Always 17. Is your skin prone to hives, wheal, or urticaria? Never Rarely Sometimes Frequently Always 18. Have you ever experienced skin purpura (purple blood stasis and bruises) due to allergies? Never Rarely Sometimes Frequently Always Please select your age group Below 28 28-35 35-45 45-60 Above 60 Name (First, Last) * Phone # Email * Note If you are human, leave this field blank. Submit