Chinese Medicine Evaluation

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Acupuncture treatments and natural remedies are successful when practitioners have a deep understanding of their patients' health histories and lifestyles. Please help us provide you with the best experience possible by spending at least 5 to 7 minutes answering the following questions about your health. There are no right or wrong answers. Reflect on yourself as honestly and realistically as possible for the most accurate analysis. You can choose more than one option in each response. Thank you!

Name: *

Date: *

YYYY

1. Fever and Chills

Fever and chills give us an idea if there are any internal or external pathogens attacking the body. If you don't experience such fluctuations in body temperature, skip to question 2.

Please check the phrase(s) that best describe your fever or chills.

Simultaneous chills and fever at beginning of disease

Chills predominant

Fever predominant

Chills without fever

Fever without chills

Slight fever occurring at a definite time of the day

Alternating chills and fever

Constant fever that rises during the evening

Fever rises during the night

Irregular periods of low fever and fatigue

Chills or cold limbs

Fever that worsens in the afternoon

Chronic low grade fever

Feel hot without fever

2. Perspiration

When and how much you sweat provides us with important information regarding potential deficiencies in the body.

Please check the phrases that describe your perspiration, if any.

Sweating

Absence of sweat

Frequent and spontaneous sweating exacerbated by slight exertion

Night sweats

Profuse cold sweat during severe illness

Sweat due to extreme heat/cold/virus/bacteria

No sweat in presence of extreme heat/cold/virus/bacteria

Sweating with no corresponding break in fever

Oily beady sweat on forehead

Sweating of the whole body

Sweating on palms, soles, and chest

3. Food and Drink/Appetite and Taste

Your appetite and tastes are useful in understanding the quality of the digestive system.

Please check the phrases that describe your appetite or thirst, if any.

Thirst with desire to take fluids

Absence of thirst or thirst without desire

Prefer hot food or beverages

Prefer cold food or beverages

Poor appetite, tastelessness in mouth and fullness in the upper abdomen and abdomen

Foul belching, acid regurgitation and aversion to thoughts or sight of food (especially after voracious eating)

Stickiness and sweetish taste in mouth

Bitter taste in mouth

Foul or sour taste

Salty taste

Rotten taste

Constantly hungry or noisy stomach

Thirsty

Dry mouth with desire to sip liquids

Fullness, bloating and/or distention after eating

Metallic taste

Lack of taste

4. Defecation and Urination

The excretory system provides valuable indications about the functioning of the kidneys and digestive system.

Please check the phrases that describe your stool, if any.

Constipation

Bloody stool with pus and continual inclination to evacuate the bowels

Loose stool with undigested food

Stool first dry then wet

Small stools

Infrequent but not dry bowel movements

If you have diarrhea, which phrase(s) best describe it?

Constant before daybreak

Massive and sudden

Long term

Frequent with continual inclination to evacuate the bowels

Urgent with yellowish and burning anus

Accompanied by abdominal pain which diminishes after the diarrhea

Frequent watery or unformed

Alternating diarrhea and constipation

Diarrhea after eating a meal

Please check the phrase(s) that best describe your urine.

Deep yellow

Clear and profuse

Frequent, scanty, and deep yellow

Frequent and clear

Retention or difficult, dribbling urination

Scanty

Excess of urine at night

Sparse

Incomplete urination

Pain with urination

5. Pain

Determining the nature and causal factors involved in pain is a significant part of treatment. Without a good understanding of the conditions underlying your pain, the long-term effects of treatment may be limited. If you don't experience any pain, skip to question 6.

Please check the phrase(s) that best describe your pain.

Pain that is aggravated by pressure

Pain that is alleviated by pressure

Pain relieved by warmth

Pain relieved by cold

Migrating

Fixed

Stabbing, stays in one place

Soreness or numbness

Sensation of heaviness

Lower back pain or pain around belly button

Lower abdominal pain

Pain in lower rib cage

Sensation of depression in the chest with shortness of breath

Bloatedness in abdominal area relieved by belching or passing gas

Pain above diaphragm

Upper abdominal pain

Pain that is aggravated by damp weather

Chest pain with cough

If you experience headaches, which phrase(s) best describe them?

Acute/severe

Persistent with repeated attacks

Empty sensation in head accompanied by sudden darkness before eyes and blurred vision

Pain at posterior/back of head

Pain on one side of head

Frontal

Pain at vertex/top of head

Exacerbated by hot environments

Pressure with sensation that head is in a bag

Distending and/or throbbing pain

Dull pain

Worse with a cold

Worse with fatigue

Worse during the day

Worse during the evening

If you experience dizziness, which phrase(s) best describe it?

Loss of balance

Spinning

Dizziness, unclear vision and ringing in ears

Worse with fatigue

Sudden onset

Gradual onset

If you experience eye pain, which phrase(s) best describe it?

Swelling and/or redness

Blurred vision ("floaters")

Dry eyes

Yellow outer layer of the eye

Abnormal eye movements

If you experience ear pain, which phrase(s) best describe it?

Sudden onset tinnitus

Chronic tinnitus

Sudden onset deafness

Gradual onset deafness

6. Sleep

Sleep is an essential component to a person's overall health. If you don't have any problems with your sleep, skip to question 7.

If you have trouble sleeping, please check the phrase(s) that best describes your issue.

Insomnia with dizziness and heart palpitations

Insomnia with restlessness in mind and dream disturbed by sleep

Difficulty falling asleep after a full meal

Irritability and difficulty falling asleep

Can't keep eyes open

Excessive sleepiness

Lethargy with dizziness

Half asleep with general fatigue

Lethargic stupor with manifestations of heat

Lethargic stupor with saliva/mucus in the throat and a thick and sticky tongue

Wakes often

7. Menses and Leukorrhea

The duration and nature of a woman's menstrual cycle gives key insights about her hormone levels and overall health.

Please check the phrases that describe your menstrual cycle, if any.

Shortened cycle, excessive in amount and deep red in color

Prolonged cycle with scanty light colored discharge

Pre-menstrual distending pain in the lower abdomen, intensifies on pressure and a dark purplish flow with clots

Post-menstrual lower abdominal pain that responds to pressure, light reddish flow that is scanty in amount

Excessive flow

Insufficient flow or lack of flow

Irregular flow

Amenorrhea (no period at all)

Early periods

Late periods

Blood clots

Please check the phrases that describe your vaginal discharge, if any.

Watery and whitish in color, little odor and accompanied with backache

Thick yellow in color with offensive smell

Irregular uterine bleeding after menopause or yellow and white vaginal discharge mixed with pus and blood

Green or red/white

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