| Male Female
| | How old are you? |
| 14-21 21-28 28-35 35-42 42-49 49-... |
| How often do you get furious, angry? |
| often seldom always angry never |
| How often do you feel being offended? |
| often seldom always never |
| How long do you remember an offense? |
| Very long forget it immediately |
| How often are you sad? |
| often seldom |
|
How long do you remember any happy event?
|
| yes no |
| How long and how often do you worry? |
| For a short time always |
| Do you have a sense of fear? |
| it passes away quickly always |
| Do you take seriously any problems?
|
| yes no |
| If you have a problem, do you think about it for a long time? |
| yes no |
| If you can't get asleep, what do you think about? |
| about the same about different things |
| How do you sleep? |
| Fast asleep sleep badly |
| Why do you wake up at night? |
| my limbs get numb go to the toilet both no |
| When you wake up in the morning, you feel... |
| live, lots of zing, vigorous clanked,flaked-out tired,weary |
| During the day you are |
| vigorous tired |
| Do your hands, fingers or legs get stiff, benumbed? |
| yes no |
| Are you sensitive to cold? |
| yes no |
| Do your hands or legs damp, clammy? |
| no damp and cold damp and warm |
| What season do you feel first-class, feel fine? |
| spring summer hot rainy season fall/autumn winter |
| What season do you feel rotten, bad? |
| spring summer hot rainy season fall/autumn winter |
| What taste do you prefer? |
| sour bitter sweet hot, spicy salty |
| What organs do you feel mostly disordered? |
| liver heart spleen lungs kidneys |
| gallbladder small intestine stomach large intestine urinary bladder |
| Do you often get sick? |
| yes no |
| Have you ever had a surgery? |
| yes no |
| What marks of excitement do you have ? |
| Reddening, flush of face turn pale no |
| Do your fingers and toes become cold and numb? |
| Yes no |
| Do your whole hands or feet become cold and numb? |
| Yes no |
| Do your fingers and toes change their color (redden or turn pale or lividity [cyanosis])? |
| Yes no |
| Do your whole hands and feet change their color (redden or turn pale or lividity[cyanosis])? |
| Yes no |
| Do you have hyperhidrosis? |
| Constantly at excitement no I do not perspire at all |
| Do you have heart consciousness, palpitation (cardiac standstill, cardiac arrhythmia, heart's sinking)? |
| Yes no |
| Do you have tightness of the chest, air thirst, hurried breathing ? |
| At excitement in a stuffy room no |
Do you have or feel a dysfunction of gastrointestinal tract:
constipation tendency, diarrhea, abdominal distention, abdominal pain, intestinal gas generation? |
| Yes no |
| Do you experience faintness, loss of consciousness or have a feeling that you can lose consciousness suddenly? |
| In a stuffy room at excitement during a long stay in a vertical position no |
| Do you have attack-like headaches? |
| Only in one half of the head all head a small part no |
| Do you have a performance decrement, rapid fatigability currently? |
| Yes no |
| Do you have sleep disturbance? |
It is difficult to fall asleep light sleep with frequent awakenings
The feeling that you slept badly, had no a good night's sleep, feeling of tiredness,
at awakening in the morning no |
| Choose one of two definitions, the most suitable for you |
| Feeling of well-being Feeling sick |
| I Feel strong I Feel weak |
| I feel able-bodied, efficient I feel fatigue, broken-down |
| Full of energy, sappy Feel washed-out |
| Feel tensed Relaxed |
| Healthy Sick,ill |
| Rested Tired,down |
| Live, green Exhausted |
| Sturdy Distressed |
| Vigorous Languid,sluggish |
| Active Passive |
| Agile, light on feet Inactive,confining |
| Fast Sluggish |
| Active, on the jump Inert,vacuous |
| Enthusiastic Impassive |
| Emotional Indifferent |
| Excited, on the high ropes Sleepy, drowsy |
| Eager to work Would like to rest |
| Quick in the uptake, nimble thinker Slow in the uptake, mind has lost its spring |
| Keep ears open, businesslike Absent-minded |
| Cheerful Sad |
| Be of good cheer Be in a bad temper |
| Happy Unhappy |
| Cheerful Be sulky,glump |
| Exaltated Dejected,blue |
| Joyful Sad,grieved |
| Quiet and confident Anxious |
| Optimistic Pessimistic |
| Hopeful,bright Disappointed,whipped-up |
| Satisfied, pleased Dissatisfied,displeased |
Here describe your real problem in details (messages without details are not considered) |
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Name, Surname / Email (Check the correctness of the e-mail inserted) |
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