ZONE QUESTIONNAIRE Health Zone Self-Analysis Questionnaire The six sections of this form deal with the SIX HEALTH ZONES: Glandular, Eliminative, Nerve, Digestive, Muscular, Circulatory. By completing this form, it will assist us in determining which Zone / Function of the body is causing or contributing to your pain or problem. Since all six Zones are interrelated, an improvement in any one Zone would also affect the others. Name* First Last Date* MM slash DD slash YYYY INSTRUCTIONS Circle the appropriate number for each question according to the following scale: ZONE ONE – GLANDULARSensitive or tender skin 0 1 2 3 Lack of energy 0 1 2 3 Get upset, irritated or short temper 0 1 2 3 Cuts in skin heal slowly 0 1 2 3 Poor memory 0 1 2 3 Poor concentration 0 1 2 3 Face flushes easily 0 1 2 3 Dry, brittle hair or oily hair/scalp 0 1 2 3 Spells of exhaustion or fatigue 0 1 2 3 Perspire a great deal 0 1 2 3 Lose control of bladder 0 1 2 3 Get up tired and exhausted 0 1 2 3 Itchy scalp, dry skin or rash 0 1 2 3 Enlarged glands 0 1 2 3 Tire easily or nervous exhaustion 0 1 2 3 ZONE TWO – ELIMINATIVEAbnormal or excessive foot odor 0 1 2 3 Have colds or chest colds/infections 0 1 2 3 Trouble with complexion 0 1 2 3 Abnormal or excessive body odor 0 1 2 3 Cough or spitting up mucus 0 1 2 3 Congested breathing or wheezing 0 1 2 3 Frequent clearing or lump in throat 0 1 2 3 Soaking sweats during sleep 0 1 2 3 Inflamed or irritated bladder 0 1 2 3 Excessive spells of sneezing 0 1 2 3 Chronic chest condition 0 1 2 3 Constipated 0 1 2 3 Nose bleeds 0 1 2 3 Diminished urination 0 1 2 3 Runny nose (not during a cold) 0 1 2 3 ZONE THREE – NERVEEyes blink or water 0 1 2 3 Loss of smell or taste 0 1 2 3 Fingernail biting 0 1 2 3 Sties, pain, or red eyes 0 1 2 3 Headaches 0 1 2 3 Stuttering or stammering 0 1 2 3 Draining, loss of hearing, ear noises 0 1 2 3 Hot or Cold spells 0 1 2 3 Difficulty falling or staying asleep 0 1 2 3 Double vision or loss of sight 0 1 2 3 Dizzy spells or faint feelings 0 1 2 3 Inability to relax 0 1 2 3 5. Lack of sensation in the body 0 1 2 3 Twitching sensation in your body 0 1 2 3 Loss of sex drive 0 1 2 3 ZONE FOUR – DIGESTIVECoated tongue 0 1 2 3 Must be careful what you eat 0 1 2 3 Bad breath 0 1 2 3 Poor appetite 0 1 2 3 Feel bloated 0 1 2 3 Bad taste in mouth 0 1 2 3 Do not eat regular meals 0 1 2 3 Indigestion 0 1 2 3 Brownish spots on skin 0 1 2 3 Eat sweets between meals 0 1 2 3 Heartburn 0 1 2 3 Pains in lower abdomen 0 1 2 3 Snack between meals 0 1 2 3 Nausea 0 1 2 3 Drink sweet drinks between meals 0 1 2 3 ZONE FIVE – MUSCULARPainful swelling in joints 0 1 2 3 Pain in feet 0 1 2 3 Muscle cramping 0 1 2 3 Muscle or joint stiffness 0 1 2 3 Back pain 0 1 2 3 Muscle spasm 0 1 2 3 Pain in joints 0 1 2 3 Neck pain 0 1 2 3 Pains in Back 0 1 2 3 Pain in arms 0 1 2 3 Tremors or shaking 0 1 2 3 Weak knees or ankles 0 1 2 3 Pain in legs 0 1 2 3 Pain or head pressure 0 1 2 3 Muscle twitches 0 1 2 3 ZONE SIX – CIRCULATORYHigh blood pressure 0 1 2 3 Out of breath easily 0 1 2 3 Numbness or tingling 0 1 2 3 Low blood pressure 0 1 2 3 Swelling of hands/ankles 0 1 2 3 Bruise easily 0 1 2 3 Pains in chest 0 1 2 3 Cold hands in hot weather 0 1 2 3 Poor circulation 0 1 2 3 Thumping of the heart 0 1 2 3 Cold feet in hot weather 0 1 2 3 Varicose veins 0 1 2 3 Heart races 0 1 2 3 Cramps in legs 0 1 2 3 Headaches 0 1 2 3
