Senstivity Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Sex

Male
Fmale

Age

Marital status

Married
Single
Divorced
widow

What kind of symptoms you see any time you face noise or light pollution.

On physical level
Emotional level
Spiritual level

How many Headaches you experience each month on average.

I seem to be aware of subtleties in my environment.

Other people's moods affect me.

I tend to be very sensitive to pain.

I find myself needing to withdraw during busy days, into bed or into a darkened room or any place where I can have some privacy and relief from stimulation.

I am particularly sensitive to the effects of caffeine.

I am easily overwhelmed by things like bright lights, strong smells, coarse fabrics, or sirens close by.

I have a rich, complex inner life.

I am made uncomfortable by loud noises.

I am deeply moved by the arts or music.

I am conscientious.

I startle easily.

I get rattled when I have a lot to do in a short amount of time.

When people are uncomfortable in a physical environment I tend to know what needs to be done to make it more comfortable (like changing the lighting or the seating).

I am annoyed when people try to get me to do too many things at once.

I try hard to avoid making mistakes or forgetting things.

I make it a point to avoid violent movies and TV shows.

I become unpleasantly aroused when a lot is going on around me.

Being very hungry creates a strong reaction in me, disrupting my concentration or mood.

Changes in my life shake me up.

I notice and enjoy delicate or fine scents, tastes, sounds, works of art.

I make it a high priority to arrange my life to avoid upsetting or overwhelming situations.

When I must compete or be observed while performing a task, I become so nervous or shaky that I do much worse than I would otherwise.

When I was a child, my parents or teachers seemed to see me as sensitive or shy.

Some life event have triggered these symptoms.

I sometimes tried to hurt myself or curse myself on the situations.

I like to close the doors and lock myself in a confined dark room.

Some days are better than the others when I feel completely fine.

Most of the symptoms get worst before, during or after menstruation.

Have you ever thoughts of going vegan.

You enjoy spicy, sour or sweet dishes

You like to enjoy fried foods.

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