5 ELEMENT QUESTIONNAIRE INSTRUCTIONS Follow the directions for each of the three questionnaires. • Total the score for each section of all three questionnaires. • For each section (A through E) add the total of Questionnaire 1 plus Questionnaire 2. o Subtract Questionnaire 3 totals from the totals of Questionnaires 1 and 2. • For example, if the score in Questionnaire 1, section A, is 20, Questionnaire 2, section A, is 15, and Questionnaire 3, sectionA, is 30, your total is 5. - Questionnaire 1 Section A = 20 - Questionnaire 2 Section A=15 A + B = 35 - Questionnaire 3 Section A = -30; then subtract this from the total above. - (20 + 15 - 30 = 5) • The sections with the two highest scores comprise your Adaptation Types; the highest score is the primary Type and the other is the secondary Type. • The code for each Type is as follows: - Section A is Wood Adaptation Type. - Section B is Fire Adaptation Type. - Section C is Earth Adaptation Type. - Section D is Metal Adaptation Type. - Section E is Water Adaptation Type. QUESTIONNAIRE 1-STRESS RESPONSE Place a score on the line next to each statement, based on the following scale: 0 = Never 1 = Rarely 2 = Occasionally 3 = Often 4 = Constantly Write the score next to each statement. Add up the score for each section and put it at the bottom of each section. Under prolonged stress, I experience the following: SECTION A __Headaches __Muscle tightness and tension __Anxiety __Frustration and irritation __Heartburn or reflux __Anger and aggressiveness __Inability to relax __Eyestrain __Hostility __Insomnia TOTAL SECTION A=__ SECTION B ___Fatigue, low energy __Depression and emotional flatness __Insomnia __Digestive bloating or diarrhea __Upper back or neck pain __Confusion and hesitation __Irritability, especially with other people __Rapid or irregular heart rate __Chest pains __Restlessness __Change in libido TOTAL SECTION B=__ SECTION C __Feeling misunderstood __Strongly needing to find support __Digestive upset __Change in appetite