CAUTION: The CCSI is a research and education tool.
The CCSI should not be regarded as a guide to self-diagnosis or self-treatment.
The cooperation of a qualified health care professional is essential if
one wishes to work with the CCSI. See the CCSI
ADMINISTRATION AND INTERPRETATION MANUAL for instructions on the
use of this instrument.
The following form may be printed out and filled
in by hand for educational purposes only. It may not be reproduced
in any form for commercial purposes.
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Name: |
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Age: |
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Date: |
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Sex: |
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SCALE 1 |
SCALE 1 |
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Cold extremities |
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Itchy or dry skin |
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Skin blemishes (eczema,
psoriasis, rash, acne, etc.) |
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Hands or feet are numb
or fall asleep |
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Lumps or tumors under skin |
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SCALE 2 |
SCALE 2 |
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| 2X |
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Kidney or bladder problems |
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Cold, clamminess over body |
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| 2X |
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Cold area on abdomen |
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Tiredness or fatigue |
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Constipation |
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Stomach or intestinal gas |
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SCALE 3 |
SCALE 3 |
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Stomach or intestinal gas |
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| 2X |
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Indigestion or "sour stomach" |
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Nausea |
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Headache |
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Bad taste in mouth |
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Constipation |
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| 2X |
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Anemia |
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General weakness and lack
of energy or vitality |
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SCALE 4 |
SCALE 4 |
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| 2X |
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Heartburn |
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| 2X |
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Belching |
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Indigestion |
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| 2X |
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Regurgitation of food |
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Constipation |
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SCALE 5 |
SCALE 5 |
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| 2X |
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Catches cold easily |
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Prone to severe colds |
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| 2X |
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Prone to congestion (head,
throat or lungs) |
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Irregular or fast pulse |
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Tiredness or fatigue |
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Abnormal appetite (increased,
decreased, erratic) |
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Skin rash |
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| 2X |
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Headaches |
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| 2X |
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Indigestion |
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Hemorrhoids |
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Stomach or intestinal gas |
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Chronic muscle pain or
diagnosis of fibromyalgia |
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SCALE 6 |
SCALE 6 |
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Indigestion |
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Constipation |
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Dull headaches |
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Pain or heaviness along
right side of abdomen |
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Bad breath or bad taste
in mouth not directly due to food or drink |
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General dullness or drowsiness |
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| 2X |
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Gallstones or gallbladder
problems |
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Burning or irritation to
eyes |
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| 2X |
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Dizziness |
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SCALE 7 |
SCALE 7 |
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Impaired or distorted sense
of taste |
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Impaired or distorted sense
of smell |
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Impaired or distorted vision |
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Impaired or distorted hearing
or tinnitus |
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Feeling of fullness in
throat or face |
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Supersensitive reactions
to sounds, actions, smells, etc. |
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SCALE 8 |
SCALE 8 |
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Decreased urination |
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Urine has strong odor |
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Burning sensation during
urination |
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Puffy under eyes or burning
of eyes or blurred/dimmed vision |
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Swelling or heaviness in
lower extremities |
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Aching muscles and/or joints
(rheumatism) |
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SCALE 9 |
SCALE 9 |
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| 2X |
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High blood pressure or
palpitations |
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Headaches |
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Lower back pain or sciatic
pain |
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Tiredness or fatigue |
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| 2X |
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Constipation |
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SCALE 10 |
SCALE 10 |
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| 2X |
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Dental problems such as
weak enamel or cavities |
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Dry, faded, or thinning
hair |
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Finger nails split or break
off |
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Poor resistance to disease |
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Low blood pressure or poor
circulation to extremities |
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| 2X |
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Weak bones, bone loss,
or bone deformity |
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Underactive thyroid |
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Tiredness or fatigue |
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Respiratory problems |
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SCALE 11 |
SCALE 11 |
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| 2X |
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Excessive bleeding (lack
of clotting) or wounds heal slowly |
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Low resistance to disease
or lack of vitality |
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| 2X |
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Cysts or tumors |
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Blotches, spots or bruises
on surface of body |
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SCALE 12 |
SCALE 12 |
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| 2X |
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Swelling or heaviness in
lower extremities |
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Lower back pain (lumbago) |
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Burning or irritation of
eyes or dimness of vision |
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Dizziness |
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Nausea |
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Headache |
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SCALE 13 |
SCALE 13 |
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Abnormal appetite (increased,
decreased, or erratic) |
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Indigestion or high acidity
in stomach, throat, or mouth |
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Stomach or intestinal gas |
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Abnormal heart action (low
or high) or discomfort around heart |
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| 3X |
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Stomach empties too slowly
or too quickly after eating |
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Headaches |
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Nausea |
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Constipation |
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SCALE 14 |
SCALE 14 |
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| 3X |
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Skin blemishes (eczema,
psoriasis, rash, acne, etc.) |
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| 2X |
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Swollen or painful joints
(arthritis or rheumatism) |
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Indigestion or stomach
or intestinal gas |
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Tender spots or painful
areas over the body |
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Nasal congestion (catarrh)
or sinus problems |
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Headache |
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Depression |
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Constipation |
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SCALE 15 |
SCALE 15 |
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Dry or thinning hair or
ends of hair split |
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Nails brittle or thin,
nails split or break, or peal around cuticle |
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Chronic dental problems |
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Dry or rough skin |
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Depression |
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Tiredness or fatigue |
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Lack of interest in sex |
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Fullness, contraction,
or choking sensation in neck or throat |
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Cold extremities |
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Poor concentration |
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Abnormal appetite (increased,
decreased, or erratic) |
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SCALE 16 |
SCALE 16 |
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Difficulty thinking or
remembering; absentminded; slow to react |
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| 2X |
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Involuntary or uncoordinated
movements (tics, twitches, tremors) |
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| 2X |
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Difficulty walking or maintaining
balance |
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Incontinence or drooling |
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Sensory system impairment
(speech, hearing, taste, or smell) |
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Conscious awareness of
involuntary process - digestion, bloodflow, etc. |
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SCALE 17 |
SCALE 17 |
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| 2X |
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History of seizures or
convulsions |
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| 2X |
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Cool or cold spot on right
side of abdomen |
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Lapse or loss of consciousness |
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Injury to tailbone or soreness
of tailbone |
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Constipation |
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Abnormal mental and physical
development |
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| 2X |
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Injury, pain or soreness
on right side of abdomen below last rib |
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SCALE 18 |
SCALE 18 |
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Anger or hate |
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Resentment, bitterness,
or jealously |
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Anxiety, worry, or fear |
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Depression |
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Hereditary predisposition
for illness or prenatal condition |
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SCALE 19 |
SCALE 19 |
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Sensory system impairment
(speech, hearing, taste, or smell) |
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Tiredness or fatigue |
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Depression |
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Constipation |
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Thinning of hair or loss
of body hair |
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Underweight |
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Splotches or blotches (white)
on skin |
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Dark circles under the
eyes |
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SCALE 20 |
SCALE 20 |
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Headache |
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Abnormal blood pressure
(high, low, or erratic) |
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Abnormal pulse (quick,
slow, or irregular) |
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Fever or temperature at
times without apparent cause |
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Feeling of fullness in
throat or face |
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Hot and/or cold sensations
(flushing) |
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Abdominal pain or aching
across lower portion of hips |
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Kidney or bladder problems |
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Constipation |
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SCALE 21 |
SCALE 21 |
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Tiredness or fatigue |
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Heart palpitations or rapid
pulse |
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| 2X |
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General weakness |
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Shortness of breath |
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Fever or temperature at
times without apparent cause |
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| 2X |
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Underweight |
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Dizziness |
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Indigestion |
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SCALE 22 |
SCALE 22 |
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| 3X |
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History of irritable bowel
syndrome or inflammatory bowel disease |
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| 2X |
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History of intestinal flu |
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Mucous in stool |
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Diarrhea |
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Intestinal gas |
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SCALE 23 |
SCALE 23 |
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| 2X |
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Pain along right rib cage,
right shoulder or arm, or upper right back |
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Constipation |
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Nausea |
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Headaches, especially after
eating |
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Fever |
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| 3X |
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Intolerance to fats or
greasy foods |
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Bad breath or bad taste
in mouth not directly due to food or drink |
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Brown, yellow, or gray
colored skin or brown splotches on skin |
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Dizziness |
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Abnormal pulse (quick,
slow, or irregular) |
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Shortness of breath |
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SCALE 24 |
SCALE 24 |
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Shortness of breath |
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| 2X |
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Cough |
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Feeling of heaviness, fullness
or pain in lungs |
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Prone to congestion (head,
throat or lungs) |
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| 2X |
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Wheezing |
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Hay fever or other respiratory
allergy |
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SCALE 25 |
SCALE 25 |
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Over or under-reactive
to stimuli, or slow to react |
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Lack of discernment or
insight |
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Poor concentration |
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Poor memory |
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Difficulty doing analysis
or calculations |
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Irrationality or delusional
thinking |
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Incoordination of movements
or reflexes, or paralysis due to stroke |
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Hallucinations |
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Lack of self control |
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SCALE 26 |
SCALE 26 |
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Slow pulse |
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Rapid pulse |
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Palpitation or throbbing
of heart |
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Low blood pressure |
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High blood pressure |
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Erratic blood pressure
(sometimes high, sometimes low) |
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Chest pain (angina) or
feeling of fullness around heart |
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Fluttering of heart |
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SCALE 27 |
SCALE 27 |
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| 3X |
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Indigestion 1 to 3 hours
after eating |
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Intestinal gas |
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Constipation |
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Diarrhea |
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Mucous in stools |
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SCALE 28 |
SCALE 28 |
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| 3X |
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Excess sugar in urine (sweet
smelling urine or high urine test) |
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| 2X |
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Urination is frequent,
excessive, or scant |
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Wounds heal slowly |
|
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| |
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Kidney or bladder problems |
|
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| |
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Impaired or distorted vision |
|
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SCALE 29 |
SCALE 29 |
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| 3X |
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Pain or discomfort on left
side of abdomen |
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Low blood pressure |
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Rapid pulse |
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Nausea |
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Highly suggestible or overly
imaginative |
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Mood swings or emotional
upsets |
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SCALE 30 |
SCALE 30 |
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Infertility |
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Abnormal sex drive (high,
low, or absent) |
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Menstrual or menopausal
problems (female) |
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Prostate problems or impotence
(male) |
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Pelvic pain or discomfort |
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