BE Alternative Medicine Evaluation Form

Balanced Energetic
Alternative Medicine Evaluation Form

If you are having trouble viewing the form on a mobile device, try viewing it horizontally.
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
My symptoms are WORSENED by (check all that apply):
My symptoms are IMPROVED by (check all that apply):
Has there been a recent change of appetite since the onset of your symptoms?

IncreasedDecreased
Do you crave any particular food? If so, what?
Do you find any particular food repulsive? If so, what?
Which ONE would you choose among the following to eat?

MeatFishCheeseEggsFruits
Do you like meat's fat?

YesNo
What kind of food did you like most as a child?
Do you suffer from excess thirst?

YesNo
If Yes, Quantity

SmallLarge
Frequency of drinking:
What are you thirsty for?

HotColdSourBitterOther
What is your favorite drink?
What is your least favorite drink?
Do you fall asleep easily?

YesNo
Do you wake up frequently?

YesNo
What is your preferred position in bed during sleep?
Are you restless during sleep?

YesNo
Do you grind your teeth while asleep?

YesNo
Do you salivate during sleep?

YesNo
If so, how much?

Large amountSmall amount
Do you talk in your sleep?

YesNo
Do you have excessive dreams?

YesNo
What do you dream about?
Do you suffer from excessive sweating?

YesNo
If so, where?

HeadHandsFeetOther
Is it a hot or cold sweat?

HotCold
Do you suffer from any of the following emotions?

AngerGriefShamefulnessFearShockConsolationAnticipationOther
How do other people think of you?
Do you have any other strange or rare and peculiar symptoms?
Do you have any tendencies for the following?

TumorsCystsPolypsWartsMolesOther
If so, where?
Do you suffer from any of the following?

RestlessnessProstrationWeaknessTrembling
Do you like to be alone?

YesNo
Do you hate to be alone?

YesNo
Did you experience any particular emotions before the onset of your illness?
What emotions are you currently strongly experiencing?
What emotions are you currently having greatest difficulty with?
What do you think is going to happen to you in the next few days?
What are you critical of about yourself?
What among your characteristics gives you most stress?
What type of things make you sad or cry?
What do you do when you are upset?
What do you regret about your life?
What are your thoughts about death?
Energy Level 1-10, with 10 being the highest?

12345678910
Time of highest energy:
Time of lowest energy:
Do you suffer from any of the following phobias?

HeightsCrowded PlacesDiseasesDead PeopleDevilAngelsDeathNarrow & Closed PlacesDarknessLosing ControlHellBeing AloneThievesAnimalsOther
If you checked Animals, which ones?
Please Check what is Appropriate to You:
Which emotion describes you best?

AngryJovialSympatheticDepressedFearful
What season do you love the most?

SpringSummerLate SummerFallWinter
What season do you hate the most?

SpringSummerLate SummerFallWinter
Which color do you like the most?

Green/BlueRedYellowWhiteBlack
Which color do you hate the most?

Green/BlueRedYellowWhiteBlack
Which taste do you like the most?

SourBitterSweetSpicySalty
Which taste do you hate the most?

SourBitterSweetSpicySalty
Which weather do you prefer the most?

WindyHotDryDampCold
Which weather do you hate the most?

WindyHotDryDampCold
Please Check what is Appropriate to You:
Please type what you see in the field below so that we can ensure that you are a real person!
Done!

Press "Submit" below. Thank you for filling this out, it will save us both time!
Should be Empty: