Acupuncture Intake Form
Please circle each symptom you have suffered from within the last two weeks.
Deficient Qi
 Weakness, lethargy, or weakness
 Lowered libido
 Decreased motivation
 Dull thinking, sensing, or feeling
 Poor appetite
 Weak digestion
 Susceptible to colds or flu
 Prolonged recovery following illness
 Pasty, pale complexion
 Limp hair
 Shortness of breath
 Averse to talking
 Perspires easily with exertion
 Weak muscles
 Chills easily
 Frequent, profuse urination
 Infertility
 Miscarriage
 Dull, soft nails
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Tongue, pale, enlarged, thin fur
Pulse, weak, soft, slow
Deficient Moisture
 Dry and thirsty
 Dryness of mucous membranes, secretions
 Constipation
 Uncomfortable feeling of heat in the body
 Restlessness and insomnia
 Low fever in the afternoon or evening
 Parched and cracked skin
 Hot flashes
 Night sweats
 Constant hunger, sometimes with weight loss
 Unstable blood sugar
 Persistent dry cough
 Dry or sore throat
 Dry brittle nails
 Flushed face with dry skin and lips
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Tongue, red no fur
Pulse, thin rapid or weak
Deficient Blood
 Restless fatigue
 Irritability
 Poor sleep
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Itching, prickling skin or scalp
Dryness without thirst
Blurred or weak vision
Loss or thinning of hair
Dizziness
Dry or hard stool
Premature aging of skin
Dry skin, eyes, hair
Anemia
Numbness of hands and feet
Muscle cramps
Lack of semen
Scanty or irregular menstruation
Pale, waxy, sallow complexion
Easy bruising
Poor skin healing
Palpitations
Postpartum weakness or anemia
Pale, opaque, thin, weak nails
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Tongue, pale pink or orange (and lips)
Pulse, weak, thin, or irregular
Slack Qi
 Prolapse of stomach, intestines or anus
 Fecal incontinence or constant diarrhea
 Hemorrhoids
 Dizzy or weak after meal or bowel movement
 Loose or flaccid muscles
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Tongue, flabby
Pulse, weak or disappearing
Slack Moisture
 Excess secretion from eyes, nose, mouth, skin, vagina
 Seminal incontinence or premature ejaculation
 Frequent urination, enuresis, or incontinence
 Dizzy or weak following sex
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Pulse, floating, thin
Slack Blood
 Excessive or prolonged bleeding from skin, nose, lungs, stomach, intestines, bladder
 Ulcers of skin, mucous membranes, stomach, intestines
 Excessive bleeding during menses, pregnancy, or postpartum
 Bleeding hemorrhoids
 Anemia with inflammation of stomach, small or large intestines
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Pulse, thin, irregular
Stagnant Qi
 Head feels stuffy
 Distention or fullness in chest or abdomen
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Mild nausea
Gas pains, cramps, tension in stomach or intestines
Hiccups, belching, or flatulence
Constipation with gas
Vague or migratory pains
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Pulse, taut
Stagnant Moisture
 Soft or loose stool
 Bloating with water retention
 Puffy eyes, face, hands, or ankles
 Frequent but scanty urination
 Feels swollen, tender, lethargic in humid weather
 Soft swellings or enlarged lymph nodes
 Premenstrual soreness and swelling of breasts
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Pulse, soft
Stagnant Blood
 Chilliness of limbs
 Sharp pains in head, eyes, joints, internal organs
 Irregular or painful menses
 Premenstrual pain and hardness of breasts
 Painful hemorrhoids or cysts
 Elevated cholesterol
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Pulse, uneven
Obstructed Qi
 Generalized discomfort, fullness, pressure in the head, chest, limbs or abdomen
 Belching and flatulence
 Wheezing
 Difficulty swallowing
 Stitch or acute pain in abdomen
 Fullness under ribs
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Tongue, thick fur
Pulse, full, tense
Obstructed moisture
 Swollen or heavy head, limbs, or abdomen
 Tender muscles and joints
 Thick or sticky saliva or phlegm
 Sticky perspiration
 Lumps, nodules, and cysts
 Sticky or slimy stool
 Scanty urine
 Generalized water retention
 Edema of hands and feet
 Thick nauseated feeling in mouth and stomach
 Congestion in the eyes and sinuses
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Tongue, enlarged with thick cheesy fur
Pulse, slippery or soft and large
Obstructed blood
 Traumatic bruises, swellings and sprains
 Persistent, localized, stabbing, or throbbing pains, esp. in joints or viscera
 Pain aggravated at night or inactivity
 Severe cramping, numbness or paralysis
 Severe headaches
 Dark red complexion
 Red or purple lesions on skin and mucous membrane
 Angina
 Severe menstrual cramps with dark blood or clots
 Pain worse with pressure or massage
 Hard, fixed lumps
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Tongue, purplish or dark red, or spots
Pulse, strong or tense, intermittent
Patterns of penetration or accumulation of adverse climates
Heat
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Cold
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Fever, with infection or inflammation
Pain, soreness, swelling, or dryness with a burning sensation
Sores/ infections with green/ yellow pus
Yellow/ green mucous discharges from ears, nose, throat, anus, vagina, urethra
Extreme thirst, craves cold drinks
Reddening of eyes, nose, ears, lips, face, skin, mucous membrane or tongue
Worse from exposure to heat or dryness
Tongue, red, yellow fur
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Cold limbs, head, chest or abdomen
Weakness with cold or clammy face, hands, or feet
Loose stool after eating raw or cold foods
Profuse urination or swelling of face or limbs upon exposure to cold climate or after
drinking cold lifquids
Cravings for warm, cooked foods and hot drinks
Pale skin, nail beds, lips, mucous membrane, or tongue
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Tongue, thick white fur, or purple
Pulse, soft, tense, slow, deep
Wind
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Erratic, spasms, cramps, or contractures of skin, nerves, vessels, muscles and viscera
Itching, prickling, twitching, and other discomfiting sensations in skin/muscles
Migrating pains appear or retreat suddenly and unpredictably
Dizziness, uncoordinated movement, and disequilibrium
Itchy, painful ears, eyes, nose, sneezing, headache, muscle soreness, or shivering when
exposed to wind or drafts
Trembling or shaking of the hands, feet, head
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Tongue, spasm or quivering
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Pulse, taut or wiry
Phlegm
 Dizziness or fullness in head with mucous congestion or nausea
 Nausea or difficult breathing with fullness in upper abdomen or chest
 Thick, sticky secretions or discharges from skin, mucous membranes, ears, eyes, nose,
throat, mouth, anus, vagina, or urethra
 Soft, mobile lumps or enlarge lymph nodes
 Worse in humid environment or from eating sticky, greasy, fatty foods, milk products,
eggs, or sugar
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Tongue, sticky or oily fur
Pulse, full, slippery
Organ network deficiency or disturbance
Liver network
 Easily irritated
 Sensitive to wind, noise, strong odors, and tastes
 Muscle tension or cramps, esp. in neck, shoulders, lower abdomen, hips, calves
 Weak or blurry vision
 Dry eyes
 Coarse brittle nails or hair
 Numbness or tingling in limbs when asleep or inactive
 Easy chilling of arms, hands, legs, feet
 Difficult elimination, dry stool, tense colon
 Weak, dizzy, flushed from hunger, tension or anger
 Irregular and/or scanty menstruation
 Nausea or queasiness from hunger or fatigue
 Genital organ hypersensitivity
 Stitching pains in ribs, beneath diaphragm, groin, and pelvic region
 Cravings for sour, spicy, fatty foods
 Tinnitus characterized by whistling or ringing
 Aggravations from heat, wind, and drafts
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Pulse, very tense or wiry
Heart network
 Easily confused
 Fatigue with anxiety and restlessness
 Slight exertion or excitement causes heat, perspiration
 Insomnia or palpitations when nervous, worried or overtired
 Frequent urination and bowel movements from nervousness
 Burning, sensitivity, or irritation of mouth, tongue, urethra, vagina or anus
 Dry mouth or throat with craving for cool drinks and juicy foods
 Easy blushing of face and ears
 Easily hot, easily cold
 Anxiety and fatigue cause light, restless sleep and vivid dreams or nightmares
 Cravings for spicy, hot, and sweet foods
 Aggravations from heat and dryness
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Pulse, large and bounding
Spleen network
 Easily worried
 Upset by changes
 Overwhelmed by details
 Lethargy and inertia
 Slow digestion of food
 Frequent abdominal gas and bloating
 Lingering hunger after meals
 Cravings for sweets and starchy foods
 Heaviness of head and limbs
 Water retention and puffiness
 Looses stool from eating raw or cold foods and liquids
 Tender muscles
 Easy or frequent bruising
 Lack of muscle tone or strength, esp. of abdomen, back or neck
 Prolapse of stomach, intestines, uterus, vagina, bladder
 Hemorrhoids
 Frequent but scanty urination
 Aggravations from cold and dampness
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Pulse, full and soft or sliding
Lung network
 Frequent colds
 Frequent rhinitis or sinusitis
 Cough with or without phlegm
 Frequent throat clearing or laryngitis
 Morning attacks of coughing or sneezing with clear phlegm or mucous discharge
 Sensitive to wind, cold, and dryness
 Dry skin and mucous membrane, esp. of face, nose and mouth
 Shortness of breath, chest pain, or wheezing in chest from fatigue or exertion
 Easily disappointed or offended
 Craves spicy, juicy, sweet foods and stimulants
 Aggravations from heat, cold and dryness
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Pulse, tense and buoyant
Kidney network
 Sore throats from fatigue
 Frequent or difficult urination
 Puffiness of swelling of feet and ankles
 Puffiness around eyes
 Dull hearing
 Tinnitus characterized by low humming
 Low back pain or soreness
 Weakness or soreness of hips, knees, ankles or feet
 Diminished libido
 Diminished motivation
 Lack of sexual secretions
 Infertility or difficulty conceiving and/or going to term
 Loss of stamina
 Needs to sleep a lot
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Easily depressed and disgruntled
Anemia
Amenorrhea
Forgetful and dull-minded
Aggravations from cold, sex, and lack of rest
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Pulse, deep, small, firm