patient complte
DESCRIPTION
asTRANSCRIPT
NAME Date
Scoring Score Card
Sr.#
15 1 1 1
3
2 Cry when thanked
5 5
3 3
1 1
3 Cry from anxiety5 1 1 5
3 3
4 Cry from self-pity
5 5
3 3
1 1
5 Moved to tears by music5 1 5
3 3
6 Relieved by crying5 1 1 5 1
3 3
7 Cry premenstrually5 1 1
3
8 Like sympathy
53
1
9 Dislike sympathy5 1 1 5
3 3
10 Sympathetic5 1 1
3
11
53
1 1
12 Tend to sigh frequently5 1 1 5
3 3
13 tend to brood or sulk5 1 1 5
3 3
145 1 1 1
3
The Constitutional Questionnaire
V.S 5
S 3
L 1
AR
G
AR
S
CA
LC
GR
AP
H
IGN
LA
CH
LYC
Cry readily (for no obvious cause)
Lack sympathy (especially toward own family)
irritable (at the least thing)
15 irritable premenstrually5 1 1 1
3
16 Easily angered5 1 5
3 3
17
5 5
3 3
1 1
18 Angry when contradicted5 1 5 5
3 3 3
19 Prone to contradict5 1 1 5 5 1
3 3 3
20 Impulsive5 1 5 1 5
3 3 3
21 Changeable and inconsistent5 1 1 5
3 3
22 Jealous5 1 5 1
3 3
23 Suspicious5 1 5 5 5
3 3 3 3
24 Critical5 1 5 5 1 1
3 3 3
25 Fastidious5 1 5 1 1
3 3
265 1 5
3 3
275 1 5 5 1
3 3 3
28 Vain
5 5
3 3
1 1
29 Egotistical5 1 1 5
3 3
dictatorial (especially at home)
Concerned with precision/accuracy
Conscientious about trivial matters
30 Ambitious5 1 1 1 1 1
3
31 Tend to theorize5 1 1
3
32 Pessimistic5 1 5
3 3
335 1 5 5 5 1
3 3 3 3
34 Anxious in company
5 5
3 3
1 1
355 1 1 5 1 5
3 3 3
36
5 5
3 3
1 1
37 anxious and cautious5 1 5 1 1
3 3
38 anxious and indecisive
5 5
3 3
1 1
39 yielding/passive5 1 1 1 1
3
40 lack confidence5 1 5
3 3
41 fearful of others' opinions5 1 1
3
42
5 5 5 5
3 3 3 3
1 1 1 1
43
5 5
3 3
Tend to worry about everything
anxious when anything is expected of you
Anxious with a hurried feeling
Avoid undertaking new things for fear of failure
Timid about public speaking (but capable)
43
1 1
445 1 5 1 5
3 3 3
45 Inhibited5 1 1
3
46 Impressionable5 1 1
3
47 Think rapidly5 1 5 5
3 3 3
48 Think slowly5 1 5 5 1
3 3 3
49
5 5
3 3
1 1
50 Tend to procrastinate5 1 5
3 3
51 restless while at work
5 5
3 3
1 1
525 1 5 5 1
3 3 3
535 1 5 1 5
3 3 3
54
5 5
3 3
1 1
55 affectionate5 1 1 1
3
565 1 1
3
57 dislike being touched5 1 1 1
3
Timid about public speaking (but capable)
Apprehensive (e.g., before a performance)
Talkative and frequently change subject
Anxious on waking in the morning
anxious about own health
suppress grief following bereavement
Feel better mentally after vigorous exercise
58 clairvoyant5 1 1 1
3
59 low sex drive (female)5 1 1 1 1
3
60 low sex drive (male)5 1 5 1 5
3 3 3
615 1 5 1
3 3
62 dislike warm foods5 1 1 5 1 1 1
3 3
63 Like raw foods5 1 1 1
3
645 1 5 1
3 3
655 1 5
3 3
66 eat to bursting point5 1 1 5
3 3
67 Fruit disagrees5 1 5 1
3 3
68 dislike fruit
5 5
3 3
1 1 1
695 1 5
3 3
70 dislike eggs5 1
3
71 Beans/peas disagree5 1 1 5
3 3
72 Like starchy foods5 1 1 5 5
3 3 3
73 Like bread and butter5 1 1
Like warm foods and drinks
lose appetite during menstruation
mixtures of foods disagree
like eggs (especially soft-boiled eggs)
73 Like bread and butter3
74 Like rich, fatty foods5 1 1
3
755 1 1 5 1
3 3
76 Like ice cream5 1 1
3
77 Like peanut butter
53
1
78 Like cheese5 1 5 1 1
3 3
79 Like olive oil5 1 5 1 5
3 3 3
80 Dislike pork5 1
3
81 like sweet foods5 1 5 1 1 5
3 3 3
82 Dislike sweet foods5 1 1 1 5 1
3 3
835 1 5 1 5
3 3 3
84
5 5
3 3
1 1
85 Pastries disagree5 1 1
3
86 Like salty foods5 1 5 1
3 3
87 Dislike salty foods5 1 5
3 3
88 Like oysters5 1 1 5 1
Rich, fatty foods cause digestive upset
Like sweet foods but they disagree
like sweet foods but not upset by them
88 Like oysters3 3
89 Dislike fish5 1 5
3 3
90 Shellfish disagree
5 5
3 3
1 1
91 Like lemons5 1
3
92 Like pickles5 1 1 1 1
3
93 Dislike tomatoes
53
1
94 Like spicy foods5 1 1
3
95 Garlic disagrees
53
1
96 Onions disagree5 1 1 5
3 3
97 Like milk
5 5 5
3 3 3
1 1 1
98 Milk disagrees5 1 1 5 1
3 3
995 1 1
3
100 hot drinks disagree
5 5
3 1 3
1
1015 1 5
3 3
Reluctant to take breast milk in infancy
iced drinks disagree
102
53
1
103 like alcohol5 1 5 1 5 1
3 3 3
104 Beer disagrees5 1 1
3
105 Little thirst5 1 1 1 1
3
106 Like coffee5 1 1
3
107 Dislike coffee5 1 5
3 3
108 Coffee disagrees5 1 5
3 3
109 Heights5 1 5
3 3
110 Enclosed spaces5 1 5 1 1 5
3 3 3
111 Crowds/public places
5 5 5
3 3 3
1 1 1
112 Mice
5 5
3 3
1 1
113 Snakes5 1 1 5
3 3
114 Water
5 5
3 3
1 1
115 Thunderstorms5 1 1 1
3
like carbonated drinks
1165 1 1
3
117 ghosts5 1 5 1 5
3 3 5
118 Darkness5 1 1 1 1
3
119 Burglars5 1 1 5 1 1
3 3
120 being alone5 1 5 5 5
3 3 3 3
121 Being late5 1 5
3 3
1225 1 1
3
123
5 5 5
3 3 3
1 1 1
124 Illness5 1 1 5 1
3 3
125 insanity5 1 1 5 1
3 3
126Cancer
5 5 5
3 3 3
1 1 1
127 death5 1 1 5 5 5 1 1
3 3 3 3
1285 1 1
3
129 Failure in business5 1 1 5
3 3
130 Poverty5 1 5 1
3 3
Sharp pointed objects (e.g., hypodermic needles)
Being hurt emotionally
Being poisoned (by bad food or pollution)
for the health of your family
131 Loss of self-control5 1 5 1
3 3
1325 1
3
133
53 3
1 1
1345 1 1 5 5
3 3 3
1355 1 1
3
1365 1 1 1 1 1
3
1375 1 5 1 1
3 3
1385 1 1 5 5
3 3 3
1395 1 1
3
1405 1 5
3 3
1415 1 1
3
1425 1 1 5 5 1 1 1
3 3 3
1435 1 1
3
1445 1 1 1 5
3 3
145 Feel better from sea air
53
Physical/mental exertion (due to lack of stamina)
Warm and made worse by heat
ailments are worse in stuffy rooms
Feet are hot in bed (stick them out bedclothes)
Chilly but made worse by heat
Chilly and better with heat
Feet are and smelly
Ailments are worse after sweating
Head is sweaty in bed
Ailments are worse from standing
ailments are worse in cold, wet weather
ailments are worse in cold, dry weather
ailments are worse in windy weather
145 Feel better from sea air
1
1465 1 1
3
1475 1 1
3
1485 1
3
149 Sensitive to smells5 1 1 1 5 5 5
3 3 3 3
1505 1 5
3 3
1515 1 1 5 1
3 3
1525 1 1
3
153
5 5 5
3 3 3
1 1 1
1545 1
3
1555 1
3
1565 1 1 5
3 3
1575 3 1 5
3
1585 3 1 1
159
5 5
3 3
1 1
Feel worse from sea air
Love to watch thunderstorms
Suffer a headache before thunderstorms
Sensitive to the smell of tobacco
Eyes are sensitiveto sunlight
Sensitive to the slightest noise
Suffer a headache or feel faint missing a meal
Feel better when fasting
Feel better after a short nap
ailments are relieved . by onset of menstruation
ailments seem worse between 4-8 a.m./p.m.
ailments seem worse between 4-6 a.m./P.m.
ailments seem worse between 1-2 a.m.
1605 1
3
1615 1 5 5 5
3 3 3 3
1625 1 5 5 5 1 1 5
3 3 3 3 3
1635 1 1 1 1
3
164
53
1
1655 1 1
3
1665 1
3
1675 5 5 5
3 3 3 3
1685 5 5 5
3 3 3 3
TOTAL 155 282 166 168 151 156 360
ailments seem worse between 2-5 a.m.
ailments are worse in the spring
ailments are worse around full moon
ailments are worse in the morning and evening
ailments are worse from sunset to sunrise
Avoid lying on the left side the body in bed
Avoid lying on the right side of the body in bed
Prone to left-sided complaints
Prone to right-sided complaints
Score Card
5 5 5 5
3 3 3 3
1
5
3
1
5 1
3
5
3
1 1 5 1
3
5 5
3 3
1 1
5 5 5
3 3 3
1 1 5 5
3 3
5 5
3 3
1 1
1 1 1 1
5
3
1 5 1
3
MER
C
NM
NV
PH
OS
PU
LS
SEP
SIL
SU
I F
1 1 1 5
3
5 1
3
1 5 1
3
1 1
5
3
5 1
3
1 1 1 1
1 1 1 5
3
1 5 5
3 3
1
1 1 5 5
3 3
5
3
1 1
1 1 5
3
5 1
3
1 5
3
1
1 1 1
5
3
1
1
1 1 1 5 5
3 3
1 1 1 5
3
5 5
3 3
5
3
1
5
3
1
5 1
3
5 1 1 1
3
5
3
1 5 1
3
5 5 1 1
3 3
1
1 1
5 1 1
3
5
3
1
1 5
3 3
5
3
5 5 1
3 3
5 1
3
5 1 5 1
3 3
5 5 1
3 3
5 5
3 3
1
1 1
5 1
3
5 1
3
5 5
3 3
1 1
1
1 5 5
3 3
1 1
5 1
3
5 1 1 5
3 3
5 1 1
3
5 1 1
3
5
3
1
5 1 1
3
1
5 1
3
1 1 1 5
3
1 1 1
1 1 5
3
5
3
1
1 5
3
5 5
3 3
1 1 1
1 1
1
1 1 1 5
3
5 1
3
5
3
1
5 5 5
3 3 3
5
3
1
1 1
5 5 5 5 5
3 3 3 3 3
1 1 1 1 1
1 1 1 1 5 5
3 3
1 5
3
5 5 5
3 3 3
1 1 1
1 1
5
3
1
5 1 1 1 5
3 3
5 1 1 1
3
5 1
3
5
3
1 1 5 1 1
3
1 5 1
3
1
5 5
3 3
5 5 5
3 3 3
1 1 1
5
3
1
1 1 5 1
3
1 1 5
3
5 5 1 5
3 3 3
1 5 1
3
1 5 1
3
5 1 1
3
1
5
3
1 5
3
1 1 1 1 5 1
3
5
3
1
1 1 5 5 1
3 3
5 1
3
1 5 1 1 1
3
1
1
1 5
3
5 5
3 3
1 1
1 5 5
3 3
1 5 5
3 3
5 1 5
3 3
5 1 1 1
3
1 5 1 5 1
3 3
5 1 1 5 1
3 3
1 1
5 5 1 5
3 3 3
1 1 5 1
3
5 1
3
5 5 5 1
3 3 3
5 5
3 3
1 1
5 5
3 3
5
3
5 1 1
3
5 5 5 1
3 3 3
1 1 1
1 5 1 5
3 3
5 1 1 5
3 3
5 5 5
3 3 3
1 1 1
5 1
3
1 5
3
1 1 1 1
1
5 1
3
5 1
3
1 1 1 1 1
1 5 5 1 5 1
3 3 3
1 5
3
5
3
1
1 5 5 1 1
3 3
5 1 1
3
5 5 5
3 3 3
5 5
3 3
85 186 214 331 339 190 152 221