Ageless Herbs Evaluation
Learn Your Imbalances According to Chinese Medicine!
Important Directions! Please Read
-You CAN skip questions that are unrelated to you.

-You will be able to view your scores immediately after completion through a link provided

-There are three separate sections to complete. A link for Part 2 will be provided at the end of Part 1 and so on.

Most people are able to discern what problems they have and are able to report them. Often times people will think, "Why should I mention the ringing in my ears when I really am worried about my back pain?" In Chinese medicine, the ringing in the ears helps to determine where the back pain is, or is not, originating from. Your results will be better with accurate information inputs.

Disclaimer
The results of this questionnaire do not constitute a diagnosis. The questionnaire is designed for you to better understand "patterns" of imbalance that you have according to Traditional Chinese Medicine. For a true diagnosis and prescription you will need to consult directly with Dr. Browne, DAOM at www.swancreekfarm.com

This form does not address acute health conditions such as a viral or bacterial infection. Not intended for children or nursing or pregnant women.
Thank you!

Part 1-Earth Element Indications
Scores indicate level of Spleen Qi Deficiency as follows:
4-16 Moderate
18-32 Significant
34+ Severe
I have been diagnosed as pre-diabetic and/or insulin resistance
2 points
I have diabetes and am able to control it with diet and good lifestyle choices
2 points
I am diabetic and depend on medication or insulin to balance my blood sugar levels
2 points
I have hypoglycemia
2 points
I crave sweets often
2 points
I feel nauseated often
2 points
I do not have a good appetite often
2 points
My tongue is scalloped along the edges
2 points
I vomit often
2 points
I am obese
2 points
I feel bloated after meals
2 points
I have dull, achy lower abdominal pain
2 points
My lower abdominal pain feels better when I apply heat or pressure
2 points
I cannot digest fatty foods or fried foods well
2 points
My body feels heavy
2 points
My arms and legs feel heavy
2 points
I have trouble getting out of bed in the morning, even after a full night's sleep
2 points
I rethink things in my mind over and over
2 points
I have weak, flabby muscles
2 points
I bruise easily
2 points
My muscles feel tender to the touch
2 points
I have a prolapse of one or more organ: uterus, bladder, vaginal, etc
2 points
I have a lot of spider veins
2 points
I have varicose veins
2 points
I sometimes have bleeding from hemorrhoids
2 points
I do not feel emotionally grounded to the Earth
2 points
I lack empathy for others
2 points
I feel like no one cares about me
2 points
I give too much of myself in the care of others
2 points
I perspire easily, even without exercise
2 points
My bowel movements are often loose often
2 points
My bowel movements are shaped like balls often
2 points
I have alternating constipation and diarrhea or IBS
2 points
My bowel movements are sticky and hard to express often
2 points
My ears fill with damp fluid often
2 points
Submit
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