Mar 6 • General discussion
5 Element Questions: Find Your Dominant Element
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
__Lethargy
__Sinus problems
__Frontal headaches
__Poor concentration
__Craving sweets
__Poor sleep
TOTAL SECTION C=__
SECTION D
__Respiratory infections
__Sadness, depression, feelings of loss
__Feeling cut off from others, distant Constipation and colon problems
__Skin problems
__Everything appearing negative
__Mental fatigue
__Nasal symptoms
__Acting critical and demanding
__Feeling Rigid and inflexible
TOTAL SECTION D=__
SECTION E
__Low back or neck pain
__Deep fatigue, poor stamina
__Feeling chilled, unable to get warm
__Fear
__Taking excessive risks
__Overwhelmed, unable to cope
__Withdrawing from others
__Neck stiffness
__Retreating, "hiding under the covers"
__Being overly cautious
TOTAL SECTION E=__
QUESTIONNAIRE 2- PERSONALITY TRAITS
This questionnaire is designed to identify tendencies that relate to the Five Adaptation Types. Please answer these as honestly as possible.
Though many of these traits are not considered desirable, answering the questions accurately will help you identify your specific Adaptation Place a score on the line next to each statement, based on the fol-
lowing scale.
0 = Strongly disagree
1 = Disagree
2 = Neutral
3 = Agree
4 = Strongly agree
Write the score next to each statement. Add up the score for each section and put it at the bottom of each section.
SECTION A
__It is hard for me to change direction after making a decision.
__I often delay making decisions
__I am disorganized at home or at work.
__I tend to challenge and question authority.
__I strongly dislike being out of control of a situation.
__I get frustrated easily.
__I strongly dislike something stopping me from achieving a goal.
__I cannot stop myself from being hard driving and overly focused on the future.
__Incompetence really bothers me.
__I have trouble controlling my hostility.
__I feel angry too often and inappropriately.
__I carry a lot of tension in my muscles.
__I can be too aggressive when stressed.
__Alcohol use can cause problems for me.
__I seem to often have conflicts with other people.
__I overreact to injustice and can take on causes inappropriately.
TOTAL SECTION A=__
SECTION B
__I have trouble seeing the humorous side of life and laughing easily at problems.
__I am not very passionate about life, relationships, or work.
__I am not naturally an optimist.
__Once I've started on a project I find it hard to maintain enthusiasm.
__I experience significant mood swings.
__I often feel very vulnerable emotionally, especially in relationships.
__I tend to be shy; it is not easy for me to make new friends.
__I often do not feel very happy or joyous.
__It is difficult for me to share my innermost feelings.
__It is very important to me that people like me.
__I can be too melodramatic.
__I feel quite anxious about many areas of my life.
__I get overwhelmed with too many choices.
__I have sleep problems when upset.
__I often feel fatigued, especially after emotional upsets.
__There was not much affection in my childhood home.
TOTAL SECTION B= __
SECTION C
__I do not feel satisfied or content with my life or myself.
__I find myself being the caregiver in relationships.
__I do not like people giving me sympathy when I have a problem.
__I feel insecure within myself.
__Food and eating play too large a role in my life.
__I have had weight problems.
__I dwell on problems too much.
__My mother did not give me enough space, and I often felt smothered.
__My mother was not very nourishing to me.
__I often want attention from others when I do not feel well.
__I do not remain calm under stress.
__I worry too much about my family and myself.
__I tend to be opinionated and do not change my mind easily.
__I don't like being asked to help others when I have my own problems.
__I tend to be too self-absorbed.
__I offer way too many details when talking about a problem.
TOTAL SECTION C=__
SECTION D
__It is hard for me to live up to my own expectations.
__I get upset when I don't get clear guidelines at work or in relationships.
__I do not express emotions easily.
__I have many regrets about my life.
__I am frequently sad or melancholic.
__I am rigid and inflexible once my mind is made up.
__I have problems with feeling good about myself.
__I hold onto grudges, especially when I feel wronged by someone.
__I often had difficulty pleasing my father; he was critical of me.
__I do not get the respect I deserve from family or work.
__It is hard to gain my respect.
__I am easily offended by improper conduct.
__I tend to withdraw and cut myself off from others when upset.
__I am often critical of others.
__It takes me longer to get over a loss than it does for other people.
__I am too materialistic.
TOTAL SECTION D=__
SECTION E
__I often focus on risks and dangers.
__I have difficulty trusting that everything will be all right.
__I feel overwhelmed, unable to cope.
__I "hibernate" when upset.
__I am cautious and careful.
__I often feel quite fragile physically or emotionally.
__I often have fears that are probably unwarranted.
__I can be suspicious and mistrusting of people's motives.
__I do not like to let people know what I am thinking or feelng.
__I often look for reassurance that everything is all right.
__I get easily depleted; my reserves are not good.
__I take on too much and often do not know my own limits.
__I often push until I am exhausted.
__I see myself as very ambitious.
__I take excessive risks.
__I am very persistent even when it's not appropriate.
TOTAL SECTION E=__
QUESTIONNAIRE 3-ADAPTATION ABILITIES
The statements in this questionnaire describe how you might respond to stressful situations. Grade these statements based on how you have responded to previous stressful situations.
Place a score on the line next to each statement, based on the following scale.
0 = Strongly disagree
1 = Disagree
2 = Neutral
3 = Agree
4 = Strongly agree
Write the score next to each statement. Add up the score for each section and put it at the bottom of each section.
SECTION A
__I tend to get more focused and effective under stress.
__I am good at figuring out what needs to be done.
__I am good at seeing the whole situation, making a new plan, and executing it well.
__I am decisive.
__I don't let anyone push me around.
__I can fight through a problem.
__I enjoy being competitive.
__I Like to do things my way when under stress.
__I rarely lose or shy away from an argument.
__I am comfortable directing or leading others.
__I dislike being criticized.
__I have a clear vision of how I want the future to look.
TOTAL SECTION A=__
SECTION B
__I maintain a strong desire to be with friends even if I am stressed.
__I am usually energetic and enthusiastic.
__I am an optimist and remain positive in my outlook, I take initiative and am able to overcome hesitation and doubts.
__I am action oriented under stress.
__I am confident, generous of spirit, and warm.
__I have good communication skills.
__I am passionate and expressive of affection.
__I stay happy, lighthearted, and playful- I see the humor in life even when stressed.
__I enjoy emotional intimacy and can share my innermost feel-ings.
__I am able to set priorities well.
__I am good at sorting information well, without hesitation.
TOTAL SECTION B=__
SECTION C
__I am caring, considerate, empathetic, and concerned about others
__When under stress, I see myself as well grounded, stable, reliable, and predictable.
__I remain calm under stress.
__People often turn to me for support and understanding.
__I am a consensus builder, tactful, and diplomatic.
__I am thoughtful and able to clearly form my own opinions and ideas.
__I go out of my way to help others when we are all under stress.
__I am friendly and create networks of friends.
__I am or would be a nourishing and supportive parent.
__I do not obsess about problems.
__I feel contented, secure, and satisfied with myself.
__I am considerate and agreeable.
TOTAL SECTION C=__
SECTION D
__I feel quite confident in my ability to persevere in difficult situations.
__I am very reliable during stressful times.
__I do not hold onto grudges, emotional upsets, or negative emotions.
__I do not dwell on losses and regrets.
__I prefer a neat, orderly, and well-defined lifestyle.
__I value virtue, a strong moral code and principles, over fulfillment or pleasure.
__I often prefer to handle stressful situations on my own.
__I keep my emotions under control when stressed.
__I maintain a quiet resolve.
__I have the deeper strength needed to deal with stress.
__Being outdoors in nature helps me deal with stress.
__I deal with stress in a logical, precise, methodical, and structured manner.
TOTAL SECTION D=__
SECTION E
__I feel I have the wisdom to know what is to be done in most stressful situations.
__Expanding my base of knowledge and seeking teachers are important to me.
__I am courageous and determined.
__I strongly trust that stressful situations will be resolved.
__I am relatively fearless.
__I have a strong will to succeed and survive.
__Under stress I feel determination and have great inner resources.
__I am quietly relentless and persistent in getting to a solution.
__I am careful, cautious, and perceptive of risks and dangers.
__I am clever and intelligent in matters of survival.
__I am confident and know my limits in what I can handle in a stressful situation.
__I can overcome significant obstacles.
TOTAL SECTION E=__
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5 Element Questions: Find Your Dominant Element
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