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Health Survey

Please mark to what degree the following statements apply to you.

I tend to feel obstruction/blockages in the body
0%
25%
50%
75%
100%

(Constipation, congestion/heaviness in the head area, blocked nose, general feeling of non-clarity, or other)

When I wake up in the morning, I do not feel clear; it takes me quite some times to feel really awake.
0%
25%
50%
75%
100%
I tend to feel tired or exhausted mentally and physically.
0%
25%
50%
75%
100%
I get common colds or similar ailments several times a year.
0%
25%
50%
75%
100%
I tend to feel heaviness in the body.
0%
25%
50%
75%
100%
I tend to feel that something is not functioning properly in the body.
0%
25%
50%
75%
100%

(breathing, digestion, elimination, or other)

I tend to be lazy, e.g., the capacity to work is there, but there is no inclination.
0%
25%
50%
75%
100%
I often suffer from indigestion.
0%
25%
50%
75%
100%
I tend to have to spit repeatedly.
0%
25%
50%
75%
100%
Often I have no taste for food and no real appetite.
0%
25%
50%
75%
100%
My tongue is often coated especially in the morning.
0%
25%
50%
75%
100%
Date
Day
Month
Year
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