Self-Assessment Health Profile

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2 Self-Assessment Health Profile This profile can be used as an educational device as well as a diagnostic tool. It will aid you in becoming acquainted with the language of Chinese medicine. Check the symptoms you have experienced during the last six months. (Example: q 3 ) Check and circle the symptoms that have been most troublesome. (Example: q 3 ) Patterns of Deficiency Qi Deficiency q Reduced appetite q Shortness of breath q Spontaneous daytime sweating q Pale face q Weak voice q Slight sensitivity to cold Spleen Qi Deficiency q Limbs feel heavy and weak q Tendency to bloat after eating q Problems digesting food after eating q Appetite low or erratic q Poor concentration q Food intolerances q Anemia q Prolapse Stomach Qi Deficiency in morning q Lack of taste q Weak limbs q Discomfort in epigastrium Lung Qi Deficiency q Weak, low voice q Lack of desire to talk q Weak breathing pattern q Tendency to collect sputum in the lungs q Shortness of breath on exertion q Weak cough q Tendency toward coughs and colds q Tendency to daytime sweating Kidney Qi Deficiency q Frequent urination q Weakness or achiness in the lower back q Weakness of the skeletal structure especially at the knees or ankle q Poor retention of urine and/or sexual fluids q Chronic vaginal discharge q Some shortness of breath q Tendency to feel chilled q Prolapse of uterus Heart Qi Deficiency q Shortness of breath on exertion q Lethargy and a lack of spiritedness q Spontaneous sweating Yin Deficiency q Low grade fever especially during the afternoon q Feeling of heat in palms, soles and upper chest or face q Flushed cheeks q Dry throat at night q Night sweats q Emaciation q Insomnia (shallow sleep with frequent waking) q Nervousness Kidney Yin Deficiency q Dizziness/vertigo q Low frequency ringing in the ears q Hearing loss q Memory loss q Adrenal hyperactivity q Aching lower back q Deep ache in the bones (feeling bone tired ) q Low sperm production q Nocturnal emissions q Blood in urine Liver Yin Deficiency q Disturbed sleep q Irritability q Dry stools q Numbness in the limbs q Scanty or absent menstruation q Dry eyes q Depression q Hypertension Stomach Yin Deficiency q No appetite q Dry mouth q Dry stools q Thirst without desire to drink q Feeling full after eating

3 Lung Yin Deficiency q Dry or tickly throat q Irritating but unproductive dry cough q Blood in sputum Heart Yin Deficiency q Feeling of restlessness q Forgetfulness q Intense dreaming q Easily startled Yang Deficiency q Feeling cold q Cold limbs q Fear of cold q Feel worse in winter/better in summer q Lack of thirst q Desire for hot drinks q Pale face q Loose watery stools q Frequent pale urination q Lack of motivation q Timidity Kidney Yang Deficiency q Aching lower back q Cold and weak knees q Weak bladder q Pale, copius urine q Loose watery stools q Oedema in the lower body q Impotence in men and infertility in women q Loss of hearing Spleen Yang Deficiency q Tendency to bloat after eating q Oedema q Low appetite q Bloating and tiredness after eating q Chilliness q Cold limbs Heart Yang Deficiency q Lethargy q Shortness of breath on exertion q Discomfort around the heart q Depression q Cold hands q Profuse sweating Blood Deficiency q Pale and dull complexion q Dizziness on standing q Blurred vision or floaters q Dry lusterless hair q Pale lips q Scanty or absent menstruation q Poor memory q Difficulty getting to sleep q A general sense of anxiety and slight depression Liver Blood Deficiency q Visual disturbance q Floaters in field of vision q Numbness or weakness or mild spasm in the muscles and tendons q Weak or pale fingernails q Dizziness q Scanty, light or even absent menstruation Heart Blood Deficiency q Insomnia q Anxiety q Intense dreaming q Forgetfulness q Easily startled q Dizziness Essence Deficiency q Slow physical development q Poor skeletal development q Late closure of fontanelle q Premature aging q Greying or falling of hair q Senility q Poor teeth q Brittle bones q General reproductive weakness Patterns of Excess Internal Heat q Fever q Redness q Inflammation q Thirst q Red eyes q Burning sensations q Scanty, dark urination q Constipation q Yellow coating on tongue Internal Cold q Chilliness q Desire for warm places, food and drink q Abdominal pain that feels worse for pressure q Lack of thirst q Abundant clear urination q White coating on the tongue q Pale face q Blue-tinged tongue, lips or extremities

4 Internal Dampness q Feeling of bodily heaviness q Lack of appetite q Feeling of congestion in or just below the chest q Difficulty passing urine q Sticky taste in the mouth q Dirty or sticky discharges q Muzzy head Dampness in Spleen q Full feeling in epigastrium q Nausea q Low appetite q Loose stool q Muzzy head q No taste or unpleasant sweet taste in mouth q Feel tired and heavy q Sticky yellow coating on tongue Dampness and Heat in Liver and Gallbladder q Fever q Dark, scanty urine q Fullness in and below chest q Nausea, maybe vomiting q Abdominal distension q Inability to tolerate fats q Bitter taste in mouth q Jaundice q Vaginal itching and/or discharge Dampness and Heat in Large Intestine q Abdominal pain q Diarrhea q Smelly stools q Mucus or blood in stool q Burning in anus q Feeling of heaviness Phlegm in the Lungs q Chronic coughing fits q Pale sputum q Shortness of breath q Stuffy feeling in chest q Worse for lying down q White coating on tongue Phlegm and Heat in the Lungs q Yellow or green phlegm q Barking cough q Stuffiness of chest q Shortness of breath q Yellow coating on tongue Dampness and Cold in Bladder q Difficult, frequent and urgency urination q Pale, cloudy urination q Heavy feeling in urethra Dampness and Heat in Bladder q Difficult, frequent and urgent urination q Burning sensation when urinating q Dark yellow, cloudy urine q Blood in urine Invasion of Wind q Sudden onset q Wandering pain and agitation mostly affecting the upper parts of the body q Aversion to wind and cold/ reluctance to go outside q Chilliness q Occipital ache/stiff neck q Runny nose q Sneezing Invasion of Wind Heat q Moderate fever q Shivering q Sneezing q Cough q Stuffy or runny nose with yellow mucus q Swollen tonsils q Sore throat q Thirst q Mild sweating q Aversion to cold Invasion of Wind Cold q Chills q Shivering q Aches and pains q Stiffness and little or no fever q Itchy throat q Sneezing q Coughing q Occipital headache q Runny nose q No sweating q No thirst q Aversion to cold Invasion of Wind Damp q Puffy, swollen eyes and face q Aversion to wind q Cough with watery mucus q Sweating q No thirst q Itchy skin and rashes which move from place to place q Painfully swollen joints and aching muscles q Symptoms are worse for humidity q General feeling of heaviness

5 Stagnation of Qi q Frustration q Distension of abdomen or throat q Tenderness beneath ribcage q Wandering distending pains q Depression and irritability q Volatile moods q Frequent sighing q Symptoms worse for stress q Purplish tongue Liver Qi Stagnation q Frustration or inappropriate anger q Tenderness and distension beneath ribcage or in chest q Feeling of lump in the throat q Lumps in groin or breast q Breast tenderness before menstruation q Irregular periods q Menstrual pain q Digestion easily disturbed by stress q Belching Liver Blood Stagnation q Premenstrual pain q Dark, clotted menstrual blood q Abdominal lumps Heart Blood Stagnation q Oppressive discomfort in chest q Cold hands q Heart pain radiating towards or along left arm Stagnation of Blood q Pain which is stabbing and fixed in one location q Purple lips and tongue q Fixed abdominal lumps q Bleeding with dark blood and a tendency towards blood clots q Premenstrual pain

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