Self-Assessment Health Profile

Natural Medicine Self-Assessment Health Profile Name: ______Date: ______

This profile is used both as an educational device as well as a diagnostic tool. It will aid you in becoming acquainted with the terminology of Natural Medicine and help you in understanding its philosophical concepts.  Check all the symptoms you have experienced in the last six months.  Circle and check all those that have been most troublesome or those specific symptoms that most apply to you.

Patterns of Depletion

Deficient Qi: sweating ___ Weak, lethargic, weary ___ Constipation (stools dry and hard) ___ Apathetic ___ Flushing of the cheeks ___ Dull thinking or feeling ___ Hot flashes and night sweats ___ Dizziness after exertion ___ Nocturnal emissions with dreams ___ Excessive need for sleep ___ Little sperm amount ___ Susceptible to colds, flu’s, allergies ___ Unstable blood sugar, emotional lability ___ Prolonged recovery following illness ___ Persistent dry cough, chronic sore throat ___ Diminished libido ___ Thin body with difficulty gaining weight ___ Pale, pasty complexion ___ Shortness of breath Slack Moisture (Lack of Containment): ___ Poor Appetite ___ Excess secretions: eye, nose, mouth, skin, ___ Possible loose stools and/or vagina ___ Possible frequent urination ___ Seminal incontinence, premature ejaculation ___ Aversion to talking ___ Frequent urination or incontinence ___ Perspires easily with exertion or at rest ___ Excessive perspiration or night sweating not spontaneously associated with a warm environment or fever ___ Easily chills ___ Dizzy or weak after sex ___ Overwhelmed by mental or emotional challenges Deficient Blood: ___ Restless fatigue Slack Qi: ___ Emotional sensitivity ___ Atony or prolapse of the stomach, intestines, ___ Insomnia and anxious sleep with dreaming anus ___ Easily frightened ___ Constant diarrhea or lack of bowel control ___ Dryness without thirst ___ Hemorrhoids, varicose veins, gastroptosis ___ Blurred or weak vision ___ Dizzy or weak after bowel movement ___ Thinning of the hair ___ Well-being followed by sudden exhaustion ___ Dry or hard stools ___ Feeling of a down bearing sensation or sagging ___ Dry skin, eyes, hair, and nails distention ___ Anemia ___ Possible urinary frequency or incontinence ___ Muscle cramps, especially of the calves ___ Weakness of the muscles and tendons Deficient Moisture (Yin): ___ Burning pains of the muscles ___ Parched mouth, thirsty ___ Lack of semen ___ Extreme dryness of the skin or mucous ___ Scanty, infrequent, and/or irregular membranes and eyes menstruation ___ Scanty secretions or urination ___ Insufficient lactation ___ Uncomfortable feeling of heat in the body ___ Pale, sallow complexion and lips ___ Low afternoon fever or feeling of heat with ___ Poor skin healing ___ Palpitations nutrition, excessively long illness, multiple births, ___ Night sweats or extreme blood loss ___ Dizziness (postural- from standing up too quickly) Disturbed Shen: ___ Poor memory ___ Restlessness and agitation ___ History of overwork, poor nutrition, excessive ___ Tendency toward impulsiveness loss of blood, exhaustion from difficult or ___ Hypersensitivity to pain or insult prolonged illness, difficult pregnancy and ___ Sudden rage, grief, or panic childbirth, excessive thinking, or chronic sleep ___ Easily startled or frightened deprivation ___ Erratic sleep, insomnia, or disturbing dreams ___ Dull, glazed or bizarre look on face and eyes Slack Blood (Not Holding): ___ Delirium or distorted perceptions ___ Easy bruising or bleeding, blood spots under ___ Uncontrolled laughter or crying the skin ___ Incoherent speech, mental confusion, rash ___ Chronic bleeding ulcers: mouth, throat, behavior stomach, intestines, and/or vagina ___ Panic attacks, hysteria, anxiety, and/or fright ___ Excessive bleeding during menses, pregnancy, ___ Confusion associated with an inability to postpartum, or during menopause concentrate ___ Bleeding hemorrhoids and blood in the stool, ___ Drug withdrawal symptoms with pain, anxiety, urine, or sputum; nosebleeds hysteria, and confusion ___ Recent surgery or trauma ___ Threatened miscarriage Patterns of Congestion Diminished Essence: ___ Profound weakness Stagnant Qi: ___ Dizziness or vertigo, empty-headed sensation ___ Stuffy head ___ Atrophy of the muscles (loss of mass and tone) ___ Distension or fullness in the chest or abdomen and organs ___ Gas, cramps, and/or tension in the stomach and ___ Sagging or wrinkling of the skin intestines ___ Diminished sexual arousal ___ Hiccups, belching, or flatulence ___ Inability to conceive ___ Constipation or irregular bowel movements ___ Premature menopause following surgery, (may have small, bitty stools or have constipation chemotherapy, childbirth, or illness and alternating loose stools) ___ Amenorrhea (no menstruation), possible pain ___ Lack of peristalsis with slow digestion of food after menstruation ___ Nausea, indigestion, or reflux due to ___ Repeated miscarriages or spontaneous abortions overeating, food incompatibility, or food toxicity ___ Loosening or loss of teeth ___ Pain or tension in the abdomen due to the ___ Poor bone development or bone weakness passage of gallstones (osteopenia, osteoporosis), weakened connective ___ Spasm in the esophagus with regurgitation, tissue feeling of something stuck in the throat ___ Early thinning or graying of head or pubic hair ___ Mental depression, irritability, or gloomy ___ Decline of memory, vision, or hearing feeling ___ Progressive loss of weight or emaciation ___ Frequent sighing ___ Compromised immunity with lowered ___ Pains that are less constant and variable in resistance to infection nature, may be dull pains that move ___ Appearance of degenerative and autoimmune ___ Headaches that are tight and boring in nature diseases (arthritis, cancer, lupus, multiple sclerosis, that may be better with movement or exercise chronic fatigue syndrome, and or AIDS) ___ History of overworking, excessive sexual activity, abuse of drugs or medications, inadequate Obstructed Qi: ___ Acute severe discomfort, fullness, and/or pressure in the head, chest, limbs, or abdomen ___ Abdominal bloating but unable to release gas ___ Absent, scanty, restricted, or painful urination ___ Wheezing and chest pain ___ Loose, watery stools ___ Difficulty swallowing, as if something were ___ High blood pressure accompanied by water stuck in the throat retention or reduced urination ___ Stitch or acute pain in the abdomen, ribs, and ___ Enlarged lymph nodes associated with chronic flanks allergies or inflammations ___ Acute indigestion, diarrhea, or constipation ___ Thick and nauseated feeling in the mouth, with severe cramping, belching, nausea, and stomach, and head flatulence ___ Symptoms made worse in humid, cold weather ___ Fullness or dull pain under the ribs or sternum ___ Stomach hyperacidity, difficulty swallowing or Stagnant Blood: regurgitation ___ Easy bruising due to abrasion, contusion, or ___ Chronic, stubborn constipation with pain sprains ___ Abdominal masses that wax and wane in size ___ Cold hands and feet ___ Irregular or painful menses Rebellious Qi: ___ Mottling, numbing, and chilling of the limbs ___ Belching, hiccoughs, nausea, or vomiting ___ Sharp, persistent, localized pains in the head, ___ Headache, dizziness, irritability eyes, joints, breasts, and organs ___ Cough, asthma ___ Mid-cycle/premenstrual pain with tender ___ Mental restlessness, insomnia breasts, irregular and intermittent menstruation ___ Painful or engorged varicose veins Stagnant Moisture (Damp): ___ Painful hemorrhoids, cysts, or lumps ___ Soft or loose stools ___ Elevated blood pressure, elevated cholesterol ___ Puffy eyes, face, hands, or ankles ___ Frequent, scanty, or difficult urination Obstructed Blood: ___ Nausea with excess saliva or fluid in the ___ Angina (heart pains) stomach ___ Severe or constant headache that is fixed and ___ Nausea or indigestion with loose stools and feels stabbing, may be associated with engorgement reduced urination of blood vessels ___ Urinary frequency with decreased output that is ___ Traumatic bruising, swelling, and sprains cloudy in color ___ Stabbing or throbbing aches and pains ___ Lethargic in humid weather ___ Pain aggravated at night or from inactivity ___ Stuffiness of the ears, nose, sinuses, and throat ___ Severe cramping, numbness, or paralysis of the especially after eating arms and legs ___ Soft swellings, cysts, and/or enlarged lymph ___ Dark red or purple complexion and lips nodes ___ Purple lesions on skins, tongue, mouth, or lips ___ Premenstrual bloating and edema with swelling ___ Severe menstrual cramps with dark blood clots of the breasts ___ Blood clots, varicose veins, hemorrhoids ___Tender muscles and sore joints, especially in ___ Feeling of oppression in the chest humid weather ___ Coughing up dark blood ___ Dry but thirsty ___ Severe epigastric pain with vomiting of dark blood Obstructed Moisture (Damp): ___ Severe abdominal pain, blood in the stools that ___ Swollen or heavy head, limbs, low back, or may be black or dark in color pelvis ___ Stools that are pencil thin like in nature ___ Swollen, sores muscles and joints ___ Hard or immobile lumps, masses, or organs ___ Excess saliva, mucus, or perspiration ___ Hypertension, elevated cholesterol ___ Edema of the hands, feet, face, or abdomen Adverse Conditions ___ Swelling of the testicles, painful ovarian cysts ___ Difficulty breathing with excess fluid in the Heat: chest or abdomen ___ Fever or feverishness, hot flashes ___ Severe infections, inflammations, or allergic ___ Sticky, yellow, or green discharge from the ear, reactions nose, throat, bronchi, urethra, or vagina ___ Pain, soreness, swelling, or dryness with a ___ Hot flashes with profuse perspiration that is sensation of heat or burning sticky; sweating may be only from the head ___ Sores or infections with green or yellow pus ___ Fever or heat not relieved by perspiring or that may be blood streaked drinking, often worse in the afternoon ___ Yellow, green, or foul smelling discharge from ___ Oily or greasy skin the ear, nose, throat, anus, vagina, or urethra ___ Loose or sticky stools streaked with mucus or ___ Extreme thirst with cravings for cold food and pus with a foul odor, stools may be yellow or frothy drink and accompanied by fever ___ Bitter taste in the mouth, possible foul breath ___ Burning, red, oozing sores, pimples, blisters, or ___ Red eyes, ears, nose, lips, face, and skin rashes ___ Dark colored urine or darkened stool with ___ Cloudy and dark urination strong odor, possible constipation or diarrhea ___ Jaundiced complexion ___ Feeling of heat in the limbs, abdomen, chest, ___ Bitter or sticky-sweet taste in the mouth head, and genitals ___ Regurgitation of bitter, acidic, or viscous fluid ___ Aggravation from alcohol, fried or spicy foods, ___ Heavy, dull, sore feeling of the limbs, muscles, and a hot environment and head ___ Worse from heat, humidity; sweet, spicy oily Cold: foods ___ Lack of thirst ___ Listless and weak External Wind: ___ Cold feeling in the limbs, head, chest, ___ Itching or prickling sensations of the skin, ears, abdomen, or genitals with possible numbness made eyes, nose better with warmth ___ Unpredictable or migrating pains ___ Pale face with cold, clammy hands and feet ___ Dizziness or headache with a cold, flu, or ___ Fear of cold or dislike for cold allergy symptoms ___ Loose stools after eating raw, cold foods and ___ Muscles soreness or shivering in wind or drafts drink with an absence of odor ___ Numbness or pain of the face or scalp ___ Constipation with abdominal pain that is severe ___ Neck stiffness or spasm, body aches and spastic ___ Headaches following minor injury or ___ Stomach and intestinal pain and rumbling after accompanying fatigue and tension from overwork ingesting cold food and drink ___ Worse from drafts, changing temperatures, or ___ Profuse urination that is odorless and colorless, pressure especially after drinking cold beverages ___ Chills and fever that are mild, may be sweating ___ Edema in a cold climate or after ingesting cold, or no sweating raw foods or drink ___ Craving warm, cooked foods with hot drink and Internal Wind: warm environments ___ Trembling hands, feet, or head ___ Pain in the head, chest, limbs, or joints ___ Disequilibrium, incoordination, clumsiness worsened by cold ___ Contracture or quivering tongue ___ Thin, odorless, colorless quality of secretions, ___ Spasms, tics, twitches, cramps of the nerves, discharge, and excretions muscles, viscera ___ Pale, purplish skin, nail beds, lips, or tongue ___ Deviation of the eyes and mouth ___ Complaints made worse in cold weather ___ Vertigo, motion sickness, hypertension ___ Giddiness with a loss of balance Damp Heat: ___ Headache with vertigo, numbness, spasms, ___ Dryness or thirst without desire or ability to parasthesia (strange sensations) drink ___ Headaches and pain that changes in location, ___ Feeling of heat in the stomach or chest with a maybe be characterized as a “pulling” sensation; nauseating taste in the mouth migraine headaches ___ Intermittent or migratory pains in the abdomen ___ Coarse, brittle nails or hair with gas or cramping of the diaphragm, stomach, ___ Touchiness from heat, wind, noise, bright light and intestines ___ Numbness, tingling of the limbs when asleep, ___ Seizures, sequellae of stroke or transischemic inactive attack ___ Muscle cramps or spasms of pelvis, sides, hips, ___ Worse from wind, changes in barometric calves, and feet pressure, over-stimulation, bright light and loud ___ Tension in the shoulders, neck, sacrum, hips, noise, and changing from lying to upright position legs ___ Emotional unpredictability ___ Migratory pains and swelling ___ Inflammation or pain of the peripheral nerves Phlegm: ___ Stitching under the diaphragm, between the ___ Dizziness (feels like the room is spinning) or ribs, groin, pelvis fullness in the head from mucus congestion ___ High pitched or loud ringing in the ears ___ Nausea with phlegm in the chest, throat, or (tinnitus) abdomen ___ Dizziness, queasy, flushed, headache from ___ Feeling of oppression in the chest and hunger or anger epigastrium, heavy feeling of the body ___ Cravings for sour foods, may crave sugary ___ Thick, sticky secretions from the ears, eyes, foods nose, throat, mouth, anus, vagina, or urethra ___ Possible bitter taste in the mouth ___ Nasal or sinus congestion accompanied by ___ Erratic appetite and digestion vertigo, dizziness, or mental dullness ___ Erratic bowel movements (alternating ___ Sores or ulcers with weeping or exudation of constipation and diarrhea) with cramping and material that is sticky and phlegm like that may be flatulence very difficult to heal ___ Hypersensitive genital organs; excessive sexual ___ Thick, greasy feeling in the mouth or dry mouth arousal with no desire to drink ___ Irregular menstrual patterns ___ Firm, mobile lumps, and cysts beneath the skin ___ Premenstrual tension, irritability, irascibility or enlarged lymph nodes, which can be soft or hard with pressure or fullness in the head, breasts, or ___ Severe or intractable headaches abdomen ___ Worse in humid environment or from eating ___ Nervous, irritable, short-tempered, feeling sticky, greasy, oily foods, milk products, eggs, or worked up sugar ___ Difficulty relaxing or “unwinding” ___ Low grade, subjective fever ___ Depression, moodiness, fluctuating mental state ___ Raw pain in the mouth ___ History of Post-Traumatic Stress Disorder ___ Constipation or sluggish stools that are sticky ___ Poor coordination, equilibrium (vertigo/poor or greasy; feel “clearer” after bowel movement balance), & locomotion ___ Intermittent feeling of something in the throat ___ Frequent sighing or yawning ___ Palpitations, anxiety, easily startled, insomnia ___ Headaches at the vertex (top of head), temporal ___ Unclarity of the mind and poor concentration region, or behind the eyes ___ Sequelae of stroke or head injury with excess ___ Headaches that feel tight/boring, throbbing, or saliva or mucus in the chest, throat, or stomach bursting in nature Organ Network Disturbances ___ Jaw tension or grinding of the teeth ___ Hypertension; vascular headaches ___ Fullness and distension of the hypogastrium Liver Network: (just over the bladder) referring to the genitals ___ Dry, red eyes; possible feeling of grit in the ___ Cramping or stabbing pain in the lower eyes abdomen or groin ___ Blurred or unclear vision, photophobia; ___ Aggravations from anger, frustration, or rectangular shaped floaters that are dark in color in pressure the visual field ___ Pain in the eyes or ears Heart Network: ___ Easy chilling of the arms, hands, legs, and feet ___ Anxiety, nervousness, dread, or panic attacks ___ Palpitations most notable on exertion ___ Restless and easily excitable, trembling ___ Irregular heart rate and/or rhythm ___ Propensity to be startled ___ Pains in the chest ___ Poor short-term memory, poor concentration ___ Collagen deterioration (lupus, rheumatoid ___ Disturbances or difficulties with speech, arthritis, marfan) thinking, and/or emotional expression ___ Easily confused or disoriented ___ Easily confused or disoriented ___ Strange distortions of perceptions associated ___ Mood swings (laughs easily, cries easily) with hunger ___ Lack emotional containment and composure ___ May be sensitive to both heat and cold ___ Changes mind frequently, especially ___ Frequent or profuse perspiration associated concerning the coarse of one’s life, feel like you are with symptoms of heat or flushing, thirst, on a “roller coaster” and that your mind is “out of palpitations, arrhythmias, tachycardia, and angina control” ___ Difficulty focusing thought and action, self- Spleen Network: doubt and indecisiveness ___ Tender muscles and fascia ___ Depression (feeling of a lack of joy) ___ Frequent and easy bruising ___ Depression and melancholy accompanied by ___ Slow digestion or indigestion anxiety and fear ___ Variable appetite ___ Life long sense of fear ___ Sweet taste in the mouth ___ Insomnia when nervous, worried, excited ___ Sores in the mouth and gums ___ Restless sleep, cannot get to sleep due to ___ Frequent abdominal gas and bloating agitation of the mind ___ Feeling of lethargy ___ Wakes frequently throughout the night but ___ Loose stools from raw or cold foods and liquid returns to sleep easily with noises in the intestines (borborygmi) ___ Wakes after 4-5 hours of sleeping and returns to ___ Bowel movement start solid and then ends sleep with slight difficulty loose; bowel movement may feel incomplete ___ Wakes after 4-5 hours of sleeping and cannot ___ Constipation, habitual with bowel movement return to sleep every 3 days or so ___ Constant waking throughout the night with ___ Hemorrhoids feeling of agitation ___ Lingering hunger after meals ___ Vivid, disturbing dreams or nightmares ___ Craving for either bitter or sweet foods ___ Awakening at night or morning with throbbing ___ Hard to gain, lose, or regulate weight and anxiety ___ Lethargy and inertia ___ Tired upon waking up in the morning even after ___ Prolapse of the stomach, intestines, vagina, or a good nights sleep bladder ___ Difficulty lying on left side or back associated ___ Loose stools with a down bearing sensation in with insomnia the abdominal region ___ Cravings for cools drinks, juicy, or hot, spicy ___ Lack of muscle tone or strength foods ___ Water retention, heaviness of the head and ___ Cravings for sweet foods and chocolate limbs ___ Sores on the tongue ___ Easy bruising, prolonged or heavy menstruation ___ Easily overheats or perspires ___ Yellow colored spots or floaters in the visual ___ Easy blushing of the face, chest, neck and ears, field especially when embarrassed or startled ___ Easily worried, obsessed ___ Burning, sensitivity or irritation of the mouth, ___ Difficulty focusing, easily distracted with tongue, urethra, vagina, or anus inability to sustain train of thought ___ Frequent urination or bowel movement from ___ Overwhelmed by details, upset by changes nervousness ___ Reddish colored spots or floaters in the visual Lung Network: field ___ Weakness of chest ___ Cardiovascular disease ___ Respiratory allergies ___ Palpitations when nervous, upset, or fatigued ___ Runny nose or stuffy sinuses, sneezing ___ Rigidity of the spine and joints, pain or stiffness ___ Feeling as if you can only breath through your of the joints mouth; weak, shallow breathing ___ Chronic problems in the upper cervical region ___ Frequent, lingering colds, coughs, throat (neck) clearing, and/or laryngitis ___ Possible feelings of coldness of the limbs, ___ Morning attacks of coughing or sneezing knees, and low back ___ Constant phlegm in the chest and throat ___ Loose or poor teeth and dental health ___ Shortness of breath on exhalation and on ___ Difficulty conceiving or carrying baby to term exertion ___ Weak or sore low back, hips, knees, ankles, or ___ Chest pain feet ___ Wheezing from fatigue or exertion ___ Lack of stamina and endurance (tired all the ___ History of asthma, bronchitis, laryngitis time), lassitude and general debility ___ History of emphysema or pulmonary disorders ___ Increased need for sleep with difficulty waking ___ Dryness and tightness of the mucous and getting out of bed in the morning membranes or skin ___ Diminished motivation and apathy, especially ___ Loss of sense of smell during the winter or in cold weather ___ Urge to urinate after laughing, coughing, or ___ Forgetfulness and mental dullness, poor long- sneezing term memory ___ Cravings for pungent foods ___ Puffiness or swelling of the feet and ankles ___ Skin rashes, eczema, and/or hives ___ Frequent and clear urination, urinary weakness, ___ Sensitivity to and poor healing of the skin dribbling after urination, nighttime urination ___ Stiffness of the neck, shoulders, and upper back (nocturia) ___ Poor venous circulatory return ___ Urinary retention or incontinence ___ Sensitivity to wind, cold, and dryness ___ Early morning diarrhea ___ Stiffness of the joints and muscles ___ Weak vision, dull hearing or loss of hearing ___ Dislikes to speak ___ Ringing in the ears (tinnitus) that sounds like ___ Squiggly or light colored lines/floaters in the cicadas or ocean waves crashing (sea shell sound) visual field ___ Central nervous system disorders (multiple ___ Easily disappointed or offended sclerosis, muscular dystrophy, cerebal palsy, ___ Emotional inhibition and sensitivity dementia, or retardation) ___ Grief or depression with soreness, heaviness, ___ Sore throat from fatigue or in the morning and constriction of the chest ___ Chronic anemia with long-term history ___ Cravings for salty foods ___ Severe prolonged feeling of fear ___ Easily defeated and disgruntled Conflicts Between Organ Networks Kidney Network: ___ Puffiness around the eyes Liver – Spleen Disharmony: ___ Round, dark spot or floaters in the visual field ___ Cold hands and feet with feeling of fullness in ___ Diminished libido and capacity for sexual the throat, chest, or abdomen pleasure, impotence ___ Indigestion with nausea, bloating, flatulence, ___ Premature ejaculations or nocturnal emissions and belching ___ Lack of sexual secretions ___ Erratic elimination (constipation and/or ___ Feel depleted after sexual activity diarrhea) ___ Loss or thinning of pubic hair ___ Spasms, pain of the esophagus, stomach, ___ Early cessation of menses, irregular cycle, intestines and uterus possible pain after menstruation ___ Thirst for alternately cold and hot liquids ___ History of delayed sexual reproductive maturity ___ Sensitivity or aversion to strong odors, flavors, ___ Early menopause ___ Erratic cravings for fatty, sour, or sweet foods ___ Disorders of urination ___ Erratic appetite, difficulty knowing what to eat ___ Tenderness, tension, and heaviness in the ___ Nervousness or mood swings alternating with muscles, especially of the head, neck, jaw, elbows, fatigue and lumbar weakness or knees ___ Easily overheated or chilled ___ Headache with heaviness and pressure (tight ___ Hot chest, head, ears, face, and hands with a boring or band-like) behind the eyes, with possible cold belly, buttocks, and feet nausea and/or diarrhea ___ Excessive perspiration or urination, difficult or ___ PMS with sore breasts, bloated abdomen, painful urination irritability, and lethargy ___ Easily enthused but difficult to sustain effort or ___ Sensitivity to light, noise, heat, humidity excitement ___ Variable blood sugar ___ Melancholy and restless after prolonged mental ___ Eating disorders or physical exertion ___ Possible nausea or vomiting ___ Sexually excitable but difficult to sustain ___ Irritable bowel, food sensitivities or intolerance arousal or achieve release ___ Flatulence, pain or distention in the ribs ___ Menstruation that fluctuates between early and ___ Moodiness or anger late ___ Vacillates between assertiveness and ___ Anxiety, despair, and/or phobias ambivalence, irritability/nervous tension and ___ Nausea, diarrhea, and urinary frequency lethargy associated with anxiety and fright ___ Alternately impulsive and vacillating, defensive ___ Craves salty, spicy foods and stimulations and yielding ___ Pain in the upper back and sacrum ___ Sometimes irritable and hostile, sometimes ___ Chronic endometritis/cervicitis/urethritis tolerant and sympathetic ___ Hyper/hypothyroid syndrome ___ Manic-depressive syndrome Spleen – Kidney Disharmony: ___ Alternately animated and apathetic, open and ___ Slow digestion, sluggish intestines withdrawn, elated and dejected ___ Weak gums and loose teeth ___ Dryness and thirst with water retention Heart – Lung Disharmony: ___ Sore, swollen joints and muscles ___ Sensitivity to changes in temperature and ___ Heaviness, weakness, and soreness of the head, humidity (heat and dryness) neck, back, sacrum, and limbs ___ Easily overheated but can’t sweat ___ Loose or dry, small stool with bloating ___ Dry cough with heat in the throat or chest ___ Frequent, scanty, or difficult urination ___ Flushes when coughing, laughing, or sneezing ___ Easily chilled in back, belly, legs, and arms ___ Painful cough with little phlegm ___ Craves salty or sweet foods, causing ___ Heat triggers sneezing, itchy throat, or rashes constipation, dryness, and water retention ___ Dry skin with cracking, redness, and itching ___ Edema, swelling of the abdomen and legs especially from cold and dryness ___ Rheumatism ___ Light sleeper and wakes easily ___ Adrenal insufficiency (Addison’s Disease) ___ Difficult breathing or insomnia due to anxiety ___ Cystitis, urethritis, vaginitis, leucorrhea ___ Itching and/or inflammation of the vagina or ___ Prostatic hypertrophy or prostatitis urethra without discharge ___ Nausea and loss of appetite during ___ Craves spicy, hot foods and stimulants chemotherapy ___ Hives, eczema, and rashes that are worse in the ___ Distractible, insecure, volatile, apathetic, or daytime and aggravated by worry and anxiety inert ___ Easily hurt or offended ___ Alternately convivial and reclusive, enthusiastic ___ Sad or melancholic when sick and lackadaisical ___ Alternately euphoric and melancholic, hysterical or depressed Kidney – Heart Disharmony: ___ Alternately spontaneous and inhibited, excited ___ Insomnia or restless sleep alternating with and subdued heavy slumber and difficulty awakening Lung – Liver Disharmony: ___ Tense, stiff neck, shoulders, chest, loins, & hips ___ Irregular bowel movements, irritable bowel syndrome ___ Sensitivity or aversion to strong odors or flavors ___ Loss of ability to smell ___ Irregular, tense, or shallow breathing, wheezing, or sighing ___ Tight cough with difficult expectoration ___ Sensitive, easily irritated skin or mucous membranes of upper respiratory or genito-urinary tracts ___ Sensitivity or aversion to heat, dryness, wind, drafts, or sudden changes in weather ___ Feel awkward expressing feelings or reactions ___ Craving for fatty, sour, and spicy foods ___ Hives, acne, itching of the skin worse at night ___ Seasonal sinusitis or hayfever, chemical sensitivity ___ Bursitis, lumbago, or sciatica that comes and goes ___ Necks spasms and occipital or lateral headaches ___ Headaches that involved the eyes and sinuses ___ Depressed, sad, quiet, angry ___ Sensitive to rage or rejection ___ Alternately pent-up and volatile, gregarious and reserved

Please list any information to the above comments and conditions that you believe would be helpful in fully expressing your symptoms and condition:

*This intake form is an adopted version from that located in the Chinese Medicine Works Clinical Handbook by Harriet Beinfield, L.Ac. and Efrem Korngold, L.Ac., O.M.D., 2007