Patient Questionaires_Body Types

Name

First NameLast Name

Date*

Date

Gender

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

At first sight, I give the impression of being

	Yes	Unsure	No
charismatic and decisive
nimble and bold
clever
taciturn and mild-mannered
reliable
compliant
calm
cold

My overall facial outline is close to this shape:

	Yes	Unsure	No
round shape
long retangular shape
square shape
inverted triangle
equilateral triangle

My face/head is characterized by

	Yes	Unsure	No
a large head
a prominent forehead
wide width
small facial features
large facial features

On a cursory look at my eyes and eyebrows,

	Yes	Unsure	No
I have vivid, intense eyes
I have thick eyebrows
I have unusually short eyebrows
I have very dark eyes
my eyes are set distant from the eyebrows

On a cursory look at my nose,

	Yes	Unsure	No
I have a high-bridged nose
the tip of the nose is narrow and sharp
I have a big nose with a blunt tip
I have a small nose with inconspicuous nostrils
the tip of the nose is turned up
I have an aquiline nose

On a cursory look at my mouth and chin,

	Yes	Unsure	No
I have thin lips
I have thick lips
I have pouting lips
I have a big mouth
I have a protruding jaw that curls upward
I have a pointed chin
I have a square chin
I am buck-toothed
I am rabbit-toothed

On a cursory look at my ears,

	Yes	Unsuure	No
I have huge ears
I have ears with thick earlobes
I have concave ears shaped like a small bowl

When I am speaking,

	Yes	Unsure	No
I have a sonorous and forceful voice
I have a clear and ringing voice
I have a raspy voice, or I just stay quiet
I have a soft and soothing voice

Looking at my overall body frame, I am

	Yes	Unsure	No
big-boned
small-boned
fat
thin
muscular

The part of my body that is the least developed is

	Yes	Unsure	No
around the waist
around the pelvis
around the neck
around the chest

The part of my body that is the most developed is

	Yes	Unsure	No
around the back and shoulders
around the chest
around the belly (abdomen)
around the buttocks

My shoulders are

	Yes	Unsure	No
sagging downward
shifting upward
closed (chest turned inward)
open (chest turned outward)
narrow

I have

	Yes	Unsure	No
pale and dry skin
thick and rough skin
soft and gentle skin
skin covered with thick hair and numerous sweat pores
skin covered with thin hair and few sweat pores

The part of the body that puts on especially more fat when I gain weight is

	Yes	Unsure	No
the face
the chest and upper arm
the belly (abdomen)
the buttocks and thighs

Personality

	Yes	Unsure	No
I decide quickly
I do my work in one go without much ado
I achieve through tenacity and perseverance
I am patient
I am pretty straightforward and decent
I am impatient
I adhere to the principles
I deal with problems rationally without getting emotional
I have a passive life
I do not care for third opinions
I do not care for formalities or routines
I just have to be the top guy at everything
I am tolerant enough to encompass differences
I am slow
I do not bend in what I believe is right
I have an active life
I am an introvert
I am meticulous and thorough
I become uncontrollably angry when confronted with scorn or disrespect
I am a perfectionist
I rarely reveal my innermost feelings
I am stubborn
I am hotheaded
I am moody, I have my fair share of ups and downs
I rarely voice my opinions
I hate outside meddling
I have great social skills but true friends are rare
I do not socialize well and I choose my friends carefully
I give greater priority to other people’s affairs than to mine
I have many masculine traits
I have many feminine traits
I have conservative values
I have liberal values
I tend to come straight to the point
I tend to voice out what I believe to be right
I become greatly agitated when I am thwarted in my path
I am cowardly
I resist to changes in course
I always try to see the contexts surrounding an event
I rush through things in haste
I cannot decide on matters easily
I am timid
I have the drive to pull things through
I am creative
I have a tendency for self-righteousness
I do not procrastinate, I finish today’s work before the day is over
I tend to start out on a lot of stuff
I am not good at rounding up stuff
I live a sedentary life
I care a lot about how I look
I can be greedy when it comes to money matters
Money can matter
Honor is my priority
I have strong jealous tendencies

Digestion-Eating Habits

	Yes	Unsure	No
I overeat
I eat a lot in one go
I eat fast
I am a picky eater

Foods that don’t go down too well

	Yes	Unsure	No
I get stuffy from eating meat
I get stuffy from eating seafood
I get stuffy from eating greasy, rich food
I get stuffy from eating wheat products
I get diarrhea from drinking beer
get diarrhea from eating spicy food
Hard-to-chew foods (cuttlefish, peanuts) can upset the stomach

Digestive patterns

	Yes	Unsure	No
Vegetarian meals go easy on the stomach
I sometimes regurgitate food
I have no tolerance for hunger
I often have an upset stomach
I hardly drink any water
I drink water slowly and in little sips
I have well-developed taste buds that allow me to discriminate tastes minutely
I enjoy eating meat

Sleeping habits

	Yes	Unsure	No
I get insomnia when things are not going according to plan
I get insomnia with a change in the sleeping environment
I sleep lightly
I sleep with my feet sticking out of the blanket
I snore
I sleep lying face down
I sleep quietly
I go to bed early
I do not sleep into late mornings even when I am tired

Stool

	Yes	Unsure	No
I get flaccid stools
I get finger-thin stools
I get stools without fixed shape
I take long turns in the toilet
I have regular bowel habits (timewise)

Bowel habits

	Yes	Unsure	No
I do no feel particularly uncomfortable with stools coming out every 4 to 5 days
I seldom get diarrhea
I get “goat stool” (tightly packed, small balls of stool)
Changes in bowel habits are the first signs of general unwellness
Constipation can cause agitation
Exposure to stress can cause more frequent bowel movements
I have a lot of flatulence
I have frequent bouts of diarrhea
A lot comes out in stool compared to how much I eat
I have a cold lower belly

The parts of my body that sweat the most are

	Yes	Unsure	No
the face and head
the hands
the feet
the armpits
the genitals and buttocks

Sweating patterns

	Yes	Unsure	No
My genitals are cold and damp
I sweat in the face but not in the feet
I sweat at night when I am tired
I have had sticky, glutinous sweat on a previous occasion
I feel invigorated after a good sweat
I hardly sweat

Urinary habits

	Yes	Unsure	No
I am a frequent bathroom-goer
I get signs of cystitis when I am tired
I rush to the toilet right after drinking
A lot comes out in urine compared to how much I drink
My urine turns darker and loses volume when I am tired

Fatigue

	Yes	Unsure	No
I feel fatigued in the mornings
I feel fatigued in the afternoons
I feel fatigued in the evenings
I get urinary problems when I am tired
I get constipation when I am tired
My fatigue improves with sweating
I get digestive problems when I am tired
I become sensitive to odors when I am tired
I become sensitive to tastes when I am tired

Frequently found symptoms

	Yes	Unsure	No
I gather foam in the mouth
My face swells up often, especially in the eyes
I have had a premature menopause in my early forties (women only)
I get hot sensations in the palms of my hands and feet
I get stuffy and hot sensations in the back and chest
My colds start in the throat
I have had an insidious lower back pain since childhood
I gain weight when I am not healthy
I have a dry throat
I often get uncomfortable sensations of having foreign substances in the throat
My eyes feel dry
The back of my neck feels constrained
My colds start in the nose
I have cold hands and feet
I do not like cold winds
I sigh from time to time

ID, Face Picture, Body Posture Picture

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It is not medical diagnosis nor to treat specific disease. Herb formulas support to your body dysfuction. Is is not guranteed to treat medically. It helps patient's healing power, cirulation, and immune systems to improve your health conditions.

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Patient Symptoms Questionnaires