Self-Assessment Health Profile

Name*
First Last
Email*
This profile can be used as an education 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. Indicate those that have been most troublesome in the "Notes" boxes provided.
PATTERNS OF DEPLETION
DEFICIENT QI
- weak, lethargic, weary
- lowered libido
- 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
- frequent, profuse urination
Notes
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
Notes
DEFICIENT MOISTURE
- parches, thirsty
- extreme dryness of skin or mucous membranes
- scant secretions and urination
- constipation
- uncomfortable feeling of heat in the body
- low afternoon fever with sweating
- hot flashes
- night sweats
- unstable blood sugar, emotional lability
- persistent dry cough
- dry sore throat
- flushed face
Notes
SLACK MOISTURE
- excessive secretions from eyes, nose, mouth, skin, vagina
- seminal incontinence or premature ejaculation
- frequent urination or incontinence
- dizzy or weak after sex (female)
Notes
DEFICIENT BLOOD
- restless fatigue
- emotional sensitivity
- insomnia and anxious sleep
- itching, prickling skin or scalp
- dryness without thirst
- blurred or weaker vision
- thinning of hair
- light headed when fatigued
- dry or hard stool
- dry skin, eyes, hair, nails
- anemia
- muscle cramps
- lack of semen
- scanty or infrequent menstruation
- insufficient lactation
- pale, sallow complexion
- poor skin healing
- palpitations
- postpartum weakness or anemia
- tendency to miscarry
- dizzy or weak after sex (male)
Notes
SLACK BLOOD
- easy bruising or bleeding
- chronic ulcers of mouth, throat, stomach, intestines, vagina
- excessive bleeding during menses, pregnancy, postpartum, or menopause
- bleeding hemorrhoids and blood in stool, urine or sputum
Notes
DIMINISHED ESSENCE
- profound weakness
- flaccid and stiff
- 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
- thinning or graying of head and pubic hair
- loss of elasticity in tendons, ligaments, and muscles
- decline of memory, vision or hearing
- progressive loss of weight or emaciation
Notes
DISTURBED SHEN
- restlessness and agitation
- emotionally unstable
- hypersensitivity to pain or insult
- sudden rage, grief or panic
- constant anxiety, incessant worry, or mental confusion
- easily startled or frightened
- erratic sleep, insomnia or disturbing dreams
- delirium
- dull, glazed or bizarre look to eyes and face
Notes
PATTERNS OF CONGESTION
STAGNANT QI
- stuffy head
- mild nausea or acidity
- dissension or fullness in chest or abdomen
- gas pains, cramps, tension in stomach or intestines
- hiccups, belching or flatulence
- constipation or irregular bowel movements
- vague or intermittent pains
Notes
OBSTRUCTED QI
- acute generalized discomfort
- fullness, pressure in head, chest, limbs or abdomen
- abdominal distension but unable to release gas
- wheezing or non-specific chest pain
- difficulty swallowing
- stitch or acute pain in abdomen, ribs, or flanks
- fullness or dull pain under ribs or sternum
Notes
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 soreness and swelling of breasts
- sore muscle or joints
- thirsty but averse to drinking
Notes
OBSTRUCTED MOISTURE
- swollen or heavy head and limbs
- swollen, sore muscles and joints
- swollen with water retention in abdomen
- excess saliva, mucus or perspiration
- constipation alternating with watery, loose stool
- scanty or absent urine
- edema of hands, feet, face or abdomen
- thick, nauseated feeling in mouth, stomach and head
Notes
STAGNANT BLOOD
- easy bruising
- cold hands and feet
- irregular or painful menses
- mottling, numbing and chilling limbs
- sharp pains in head, eyes, joints, limbs, breasts or organs
- mid-cycle or premenstrual pin or tender breasts
- painful hemorrhoids, cysts or lumps
Notes
OBSTRUCTED BLOOD
- angina
- severe or constant headache
- traumatic bruises, swelling and sprains
- persistent, stabbing, or throbbing pains (especially in joints or visor)
- 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
Notes
ADVERSE CONDITIONS
HEAT
- fever, associated with infection, inflammation, or emotional upset
- pain, soreness, swelling or dryness accompanied by 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 dinks
- red eyes, ears, nose, lips, face, skin
- feeling of heat in limbs, abdomen, chest, head or genitals
- aggravation from alcohol, fried, or spicy food
Notes
COLD
- lack of thirst
- listless and weak
- cold feeling in limbs, head, chest, abdomen or genitals
- pale face with cold, clammy hands and feet
- loose stool after eating raw or cold foods or liquids
- profuse urination or swelling in cold climate or after drinking cold liquids or eating raw, cold foods
- craving for warm, cooked foods and hot drinks
- pain in head, chest, limbs or joints in cold environment
- pale, purplish skin, nail beds, lips or tongue
Notes
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
- hot, heavy, dull feeling in the head, chest, abdomen or limbs
- worse from heat and/or humidity and sweet, spicy or oily foods
Notes
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 when exposed to wind, drafts, or changing temperatures
- numbness or pain of face or scalp
- neck stiffness or spasm
- worse from drafts and changing temperatures
Notes
INTERNAL WIND
- trembling hands, feet, head
- spasms, twitches, cramps of nerves, muscles and viscera
- disequilibrium, in-coordination
- contracture or quivering of tongue
- 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 position
Notes
PHLEGM (congealed moisture)
- 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 or enlarged lymph nodes
- worse in humid environment or from eating sticky, greasy, oily foods, milk products, eggs, sugar
- sticky or greasy stool
- hardened nodules or cysts
Notes
ORGAN NETWORK DISTURBANCES
LIVER NETWORK
- dry eyes
- blurred or unclear vision
- nervous, irritable, short tempered
- 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 pains under diaphragm, between ribs, groin or pelvis
- dry or hard stool, tension or cramping in colon
- high pitched or loud ringing in the ears (tinnitus)
- dizzy, queasy, flushed or headache from hunger, tension, anger
- hypersensitive genital organs
Notes
HEART NETWORK
- anxiety, dread
- restless and excitable
- easily confused or disoriented
- mood swings (laughs easily, cries easily)
- insomnia when nervous, worried or excited
- excitement, anxiety and fatigue cause light, 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 movement from nervousness
- palpitations when nervous, upset or fatigued
Notes
SPLEEN NETWORK
- tender muscles
- difficult bowel movements
- slow digestion or indigestion
- frequent abdominal gas or bloating
- loose stool from raw or cold foods, cold liquids
- variable appetite
- lingering hunger after meals
- hard to gain, lose or regulate weight
- easily worried, obsessed
- difficulty focusing, distractible
- 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
Notes
KIDNEY - HEART DISHARMONY
- insomnia or restless sleep alternating with heavy slumber and difficulty awakening
- nervousness or mood swings with fatigue and lumbar weekness
- easily overheated or chilled
- hot chest, head, ears, face and hands, with cold belly buttocks and 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
- spine stiffness and lack of muscle tone
- anxiety, despair, phobias
- nausea, diarrhea, urinary frequency associated with anxiety or fright
- craves salty, spicy food and stimulants (nicotine, caffeine)
- chronic endometritis/cervicitis/urethritis
- chronic sleep disturbances
- hyper-hypothyroid syndrome
Notes
HEART - LUNG DISHARMONY
- sensitivity to changes in temperature and humidity
- easily overheated but can't sweat
- dry cough with heat in throat or chest
- flushes when coughing, laughing, or sneezing
- heat triggers sneezing, itchy throat or rashes
- dry skin with cracking, redness and itching especially from cold and dryness
- light sleeper and wakes easily
- itching and inflammation of vagina or urethra without discharge
- alternately euphoric and melancholic, hysterical or depressed
- easily hurt
- craves spicy, hot foods and stimulants
- sun allergy
- hives, eczema, rashes, worse in daytime
- chronic dry, inflamed nose and throat
Notes
LUNG - LIVER DISHARMONY
- tense, stiff neck, shoulders, chest or loins
- irregular bowel movements
- sensitivity or aversion to strong odors or flavors
- loss of ability to smell
- irregular, tense or shallow breathing
- wheezing or sighing
- 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
- craving for fatty, sour and spicy foods
- hives, itching, worse at night
- sensitive and reactive to rage or rejection
- seasonal sinusitis or hay fever
- bursitis, lumbago or sciatica that comes and goes
- neck spasms and occipital or lateral headaches
- depressed, sad, quiet, angry
Notes
Please list your additional health concerns:
This Health Profile is excerpted from Between Heaven and Earth: A Guide to Chinese Medicine (Beinfield & Korngold, Ballantine, 1991). This book is a good resource to help you understand more about Chinese Medicine, available through local bookstores.

PATTERNS OF DEPLETION

PATTERNS OF CONGESTION

ADVERSE CONDITIONS

ORGAN NETWORK DISTURBANCES