Title TCM Assessment.pdf ✅

S ELF -A SSESSMENT H EALTH P ROFILE Name __________________________________________ Date _____________________ 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. Circle and check those that have been most troublesome. Deficient Qi ___ weak, lethargic, weary ___ apathy ___ dull thinking or feeling ___ excessive need for sleep ___ susceptible to colds, flus, allergies ___ prolonged recovery following illness ___ pasty, pale complexion ___ shortness of breath ___ aversion to talking ___ perspires easily with exertion ___ easily chills Slack Qi ___ perspires easily while at rest ___ atony or prolapse of stomach, intestines, anus ___ constant diarrhea or lack of bowel control ___ hemorrhoids, varicose veins ___ dizzy or weak after meal or bowel movement ___ well-being followed by sudden exhaustion Deficient Moisture ___ parched, thirsty ___ extreme dryness of skin or mucous membranes ___ scant secretions and urination ___ uncomfortable feeling of heat in the body ___ low afternoon fever with sweating ___ constipation ___ hot flashes ___ night sweats ___ unstable blood sugar, emotional lability ___ persistent dry cough Slack Moisture ___ excess secretions: eyes, nose, mouth, skin, vagina ___ seminal incontinence, premature ejaculation ___ frequent urination or incontinence ___ dizzy or weak after sex Deficient Blood ___ restless fatigue ___ emotional sensitivity ___ insomnia and anxious sleep ___ dryness without thirst ___ blurred or weak vision ___ thinning of hair ___ dry or hard stool ___ dry skin, eyes, hair, nails ___ anemia ___ muscle cramps ___ lack of semen ___ scanty or infrequent menstruation ___ insufficent lactation ___ pale, sallow complexion ___ poor skin healing ___ palpitations ___ night sweats Slack Blood ___ easy bruising or bleeding ___ chronic ulcers: mouth, throat, stomach, intestines, vagina ___ excessive bleeding during menses, pregnancy, postpartum or menopause ___ bleeding hemorrhoids and blood in stool, urine, or sputum Diminished Essence ___ profound weakness ___ atrophy of muscles and organs ___ sagging or wrinkling of skin ___ diminished sexual arousal and pleasure ___ infertility or early menopause ___ repeated miscarriages ___ loosening or loss of teeth ___ early thinning or graying of head and pubic hair ___ decline of memory, vision or hearing ___ progressive loss of weight or emaciation ___ compromised immunity Patterns Of Depletion © 2007 Chinese Medicine Works www.chinese-medicine-works.com
S ELF -A SSESSMENT H EALTH P ROFILE - pg. 2 Name __________________________________________ Date _______________________ Disturbed Shen ___ restlessness and agitation ___ hypersensitivity to pain or insult ___ sudden rage, grief or panic ___ constant anxiety, ,worry or confusion ___ easily startled or frightened ___ erratic sleep, insomnia or disturbing dreams ___ dull, glazed or bizarre look to eyes and face ___ delerium Stagnant Qi ___ stuffy head ___ mild nausea or reflux ___ distension or fullness in chest or abdomen ___ gas pains, cramps, tension in stomach or intestines ___ hiccups, belching or flatulence ___ constipation or irregular bowel movements ___ dull or intermittent pains Obstructed Qi ___ acute discomfort, fullness, pressure in head, chest, limbs or abdomen ___ abdominal bloating but unable to release gas ___ wheezing and chest pain ___ difficulty swallowing, as if something stuck ___ stitch or acute pain in abdomen, ribs, or flanks ___ fullness or dull pain under ribs or sternum Stagnant Moisture ___ soft or loose stool ___ puffy eyes, face, hands or ankles ___ frequent, scanty or difficult urination ___ lethargic in humid weather ___ soft swellings, nodules, cysts, enlarged lymph nodes ___ premenstrual edema and swelling of breasts ___ tender muscles or joints ___ dry but thirsty Obstructed Moisture ___ swollen or heavy head and limbs ___ swollen, sore muscles and joints ___ excess saliva, mucus or perspiration ___ scanty or absent urine ___ edema of hands, feet, face or abdomen ___ thick, nauseated feeling in mouth, stomach, head Patterns Of Congestion Stagnant Blood ___ easy bruising ___ cold hands and feet ___ irregular or painful menses ___ mottling, numbing and chilling of limbs ___ sharp pains: head, eyes, joints, limbs, breasts, organs ___ mid-cycle or premenstrual pain or tender breasts ___ painful hemorrhoids, cysts or lumps Obstructed Blood ___ angina ___ severe or constant headache ___ traumatic bruises, swellings and sprains ___ stabbing or throbbing aches or pains ___ pain aggravated at night or from inactivity ___ severe cramping, numbness or paralysis ___ dark red or purple complexion ___ purple lesions on the skin, tongue, mouth or lips ___ severe menstrual cramps with dark blood or clots ___ hard or immobile lumps, masses or organs Heat ___ fever ___ pain, soreness, swelling or dryness with a sensation of heat or burning ___ sores or infections with green or yellow pus ___ yellow, green, or foul smelling discharge from ears, nose, throat, anus, vagina or urethra ___ extreme thirst with a craving for cold foods or drink ___ red eyes, ears, nose, lips, face, skin ___ feeling of heat: limbs, abdomen, chest, head, gentials ___ aggravation from alcohol, fried, or spicy foods, and heat environment Cold ___ lack of thirst ___ listless and weak ___ coldfeelinginlimbs,head,chest,abdomenorgenitals ___ pale face with cold, clammy hands and feet ___ loose stool after eating raw or cold foods and liquids ___ profuse urination or edema in cold climate or after ingesting cold liquids, eating raw or cold foods ___ craving for warm, cooked foods and hot drinks ___ paininhead,chest, limbs, joints aggravated by cold ___ pale, purplish skin, nail beds, lips, or tongue Adverse Conditions © 2007 Chinese Medicine Works www.chinese-medicine-works.com
S ELF -A SSESSMENT H EALTH P ROFILE - pg. 3 Name __________________________________________ Date _______________________ Damp Heat ___ dryness or thirst without desire or ability to drink ___ feeling of heat in stomach or chest with a nauseating taste in the mouth ___ sticky yellow or green discharge from nose, throat, bronchi, urethra, or vagina ___ hot flashes with profuse perspiration ___ fever or heat not relieved by perspiring or drinking ___ loose or sticky stool streaked with mucus or pus ___ burning, red, oozing sores, boils, pimples, blisters or rashes ___ worse from heat and/or humidity, and sweet, spicy or oily foods External Wind ___ itching or prickling sensations of skin, ears, eyes, nose; sneezing, headache ___ unpredictable or migrating pains ___ dizziness or headache with cold, flu, or allergy ___ muscle soreness or shivering in winds or drafts ___ numbness or pain of face or scalp ___ neck stiffness or spasm ___ worse from drafts, changing temperatures, pressure Internal Wind ___ trembling hands, feet, head ___ disequilibrium, incoordination ___ contracture or quivering of tongue ___ spasms, twitches, cramps of nerves, muscles,viscera ___ vertigo, motion sickness, hypertension ___ headache with vertigo, numbness, spasms, parasthesia (strange sensations) ___ seizures, sequellae of stroke or T.I.A. ___ worse from wind, changing barometric pressure, or changing from lying to upright posture Phlegm ___ dizziness or fullness in head from mucus congestion ___ nausea with phlegm in chest or throat ___ thick, sticky secretions from ears, eyes, nose, throat, mouth, anus, vagina or urethra ___ firm, mobile lumps, cysts, enlarged lymph nodes ___ worse in humid environment or from eating sticky, greasy, oily foods, milk products, eggs, sugar ___ sticky or greasy stool Adverse Conditions (continued) Liver Network ___ dry eyes ___ blurred or unclear vision ___ easy chilling arms, hands, legs, feet ___ coarse, brittle nails or hair ___ touchiness from heat, wind, noise, bright light ___ numbness, tingling of limbs when asleep or inactive ___ muscle cramps of pelvis, sides, hips, calves, feet ___ tension in shoulders, neck, sacrum, hips, legs ___ stitching under diaphragm, between ribs, groin, pelvis ___ high pitched or loud ringing in the ears (tinnitus) ___ dizzy, queasy, flushed, headache from hunger, anger ___ hypersensitive genital organs ___ nervous, irritable, short tempered Heart Network ___ anxiety, dread ___ restless and excitable ___ mood swings (laughs easily, cries easily) ___ insomnia when nervous, worried or excited ___ restless sleep and vivid dreams or nightmares ___ cravings for cool drinks, juicy or hot, spicy foods ___ sores of mouth and tongue ___ easily overheats and perspires ___ easy blushing of face, chest, neck, and ears ___ burning, sensitivity or irritation of mouth, tongue, urethra, vagina or anus ___ frequent urination or bowel movements from nervousness ___ palpitations when nervous, upset or fatigued ___ easily confused or disoriented Spleen Network ___ tender muscles ___ slow digestion or indigestion ___ variable appetite ___ frequent abdominal gas or bloating ___ loose stool from raw or cold foods and liquids ___ lingering hunger after meals ___ hard to gain, lose or regulate weight ___ difficulty focusing, distractable ___ overwhelmed by details, upset by changes ___ lethargy and inertia ___ prolapse of stomach, intestines, uterus, vagina, bladder ___ lack of muscle tone or strength ___ water retention, puffiness, heaviness of head, limbs ___ easy bruising, prolonged or heavy menstruation ___ easily worried, obsessed Organ Network Disturbances © 2007 Chinese Medicine Works www.chinese-medicine-works.com
S ELF -A SSESSMENT H EALTH P ROFILE - pg. 4 Name __________________________________________ Date _______________________ Lung Network ___ weakness of chest ___ respiratory allergies ___ runny nose or stuffy sinuses ___ frequent, lingering colds, coughs, throat clearing, laryngitis ___ morning attacks of coughing or sneezing ___ constant phlegm in chest or throat ___ shortness of breath, chest pain, wheezing from fatigue or exertion ___ dryness and tightness of mucous membranes or skin ___ urge to urinate after laughing, coughing, or sneezing ___ skin rashes, eczema, hives ___ sensitive to wind, cold and dryness ___ stiffness of joints and muscles ___ easily disappointed or offended Kidney Network ___ puffiness around eyes ___ diminished libido ___ lack of sexual secretions ___ loss or thinning of pubic hair ___ early cessation of menses, irregular cycle ___ disorder of urination ___ rigidity of spine and joints ___ difficulty conceiving or carrying to term ___ weak or sore low back, hips, knees, ankles or feet ___ lack of stamina and endurance ___ diminished motivation and apathy ___ forgetfulness and mental dullness ___ puffiness or swelling of feet and ankles ___ weak vision, dull hearing ___ low humming or buzzing in ears (tinnitus) ___ sore throat from fatigue or in the morning ___ easily defeated and disgruntled Liver - Spleen Disharmony ___ cold hands and feet with feeling of fullness in throat, chest, or abdomen ___ indigestion with nausea, bloating, flatulence, belching ___ erratic elimination, constipation or diarrhea ___ spasm, pain of esophagus, stomach, intestines, uterus ___ thirst for alternately cold and hot liquids ___ sensitivity or aversion to strong odors or flavors ___ erratic cravings for fatty, sour, or sweet foods ___ erratic appetite, difficulty knowing what to eat ___ tenderness, tension and heaviness in muscles, especially head, neck, jaw, elbows or knees ___ headache with heaviness or pressure behind eyes,nausea, diarrhea ___ sensitivity to light, noise, heat and humidity ___ variable blood sugar ___ eating disorders ___ irritable bowel ___ food sensitivity or intolerance ___ vacillates between assertiveness and ambivalence, irritability and lethargy Spleen - Kidney Disharmony ___ slow digestion, sluggish intestines ___ weak gums and loose teeth ___ dryness and thirst with water retention ___ sore, swollen joints and muscles ___ heaviness, weakness and soreness of head, neck, back, sacrum and limbs ___ loose or dry, small stool with bloating ___ frequent, scanty or difficult urination ___ easily chilled in back, belly, legs or arms ___ craves salty or sweet foods, causing constipation, dryness and water retention ___ edema ___ rheumatism ___ cystitis, urethritis, vaginitis, leucorrhea ___ prostatic hypertrophy or prostatitis ___ distractible, insecure, volatile or apathetic, inert Kidney - Heart Disharmony ___ insomnia or restless sleep alternating with heavy slumber and difficulty awakening ___ nervousness or mood swings alternating with fatigue and lumbar weakness ___ easily overheated or chilled ___ hot chest, head, ears, face and hands, with cold belly, buttocks, feet ___ easily enthused but difficult to sustain effort or excitement ___ melancholy and restless after prolonged mental or physical exertion ___ sexually excitable but difficult to sustain arousal or achieve release Organ Network Disturbances (continued) Conflicts Between Organ Networks © 2007 Chinese Medicine Works www.chinese-medicine-works.com