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Chinese Medicine Symptom Checklist
All Traditional Chinese Medicine treatments for fertility and fertility challenges are based on
restoring health and balance to the whole person, which restores health and balance to the
reproductive system. Please check the line for each symptom you have to help Dr. Whelchel
assess the imbalances in the whole body so she may customize your fertility plan for you.
KIDNEY YIN DEFICIENCY
___Do you have lower back weakness, soreness or pain or knee problems?
___Do you have ringing in your ears or dizziness?
___Is your hair prematurely gray?
___Do you have vaginal dryness?
___Is your mid-cycle cervical fluid scanty or absent?
___Do you have dark circles around or under your eyes?
___Do you have night sweats?
___Are you prone to hot flashes?
___Would you describe yourself as afraid or fearful a lot?
___Does your tongue lack coating? Does it appear shiny or peeled?
KIDNEY YANG DEFICIENCY
___Do you have low back pain premenstrually?
___Is your low back sore or weak?
___Are your feet cold, especially at night?
___Are you typically colder than those around you?
___Is your libido low?
___Are you often fearful?
___Do you wake up at night or early in the morning because you need to urinate?
___Do you urinate frequently and is the urine clear and/or profuse?
___Do you have early morning loose, urgent stools?
___Does your menstrual blood tend to be dull in color?
___Do you feel cold cramps during your period that respond to a heating pad?
___Is your tongue pale, moist and swollen?
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SPLEEN QI DEFICIENCY
___Are you often fatigued?
___Do you have poor appetite?
___Is your energy lower after a meal?
___So you feel bloated after a meal?
___Do you crave sweets?
___Do you have loose stools, abdominal pain and digestive problems?
___Are your hands and feet cold?
___Are you prone to feeling heavy or sluggish?
___Are you prone to feeling heaviness or grogginess in the head?
___Do you bruise easily?
___Do you feel you have poor circulation?
___Do you have varicose veins or spider veins?
___Are you lacking strength in your arms and legs?
___Are you lacking in exercise?
___Are you prone to worry?
___Have you been diagnosed with low blood pressure?
___Do you sweat a lot without exerting yourself?
___Do you feel dizzy or lightheaded or have visual changes when you stand up quickly?
___Is your menstruation thin, watery, profuse or pinkish in color?
___Are you more tired around menstruation or ovulation?
___Do you ever have spotting a few days before your period comes?
___Have you ever been diagnosed with uterine or bladder prolapse?
___Are your menstrual cramps accompanied by a bearing down sensation in your
uterus?
___Are you often sick or do you have allergies?
___Have you been diagnosed with hypothyroid or anemia?
___Do you have hemorrhoids or polyps?
___Does your tongue look swollen with teeth marks on the sides?
___Do you have a pale, yellowish complexion?
BLOOD DEFICIENCY
___Are your menses scanty or late?
___Do you have dry, flaky skin?
___Are you prone to getting chapped lips?
___Are your fingernails or toenails brittle or break easily?
___Are you losing hair on your head (not in patches, but all over)?
___Is your hair brittle or dry?
___Do you have diminished nighttime vision?
___Do you get dizzy or lightheaded around your period?
___Are your lips, inside of your lower eyelids or tongue pale in color?
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BLOOD STASIS
___Is your menstrual flow (not spotting) ever brown or black in color?
___Do you feel pain in your ovaries around the middle of your cycle?
___Do you have painful, immovable breast lumps?
___Do experience periodic numbness in your hands or feet (especially at night)?
___Do you have varicose or spider veins?
___Do you have red hemangiomoas (cherry-red spots) on your skin?
___Does your complexion appear dark and “sooty”?
___Do you have chronic hemorrhoids?
___Does your menstrual blood contain clots?
___Have you been diagnosed with endometriosis or fibroids?
___Is your lower abdomen tender to the touch?
___Can you feel any abnormal lumps in your lower abdomen?
___Do you have piercing or stabbing menstrual cramps?
___Does your tongue look dark?
___Do you have dark spots on your tongue?
___Are the veins underneath your tongue full and twisty?
___Do you have dark spots in your eyes?
___Have you been diagnosed with any vascular abnormality or blood clotting disorder?
LIVER QI STAGNATION
___Are you prone to emotional depression?
___Are you prone to anger and/or rage?
___Do you become irritable premenstrually?
___Do you feel bloated or irritable around ovulation?
___Are your breasts sore or sensitive at ovulation?
___Do you experience nipple pain or nipple discharge?
___Do you have premenstrual breast distension or pain?
___Have you ever been diagnosed with high prolactin levels?
___Do you become bloated premenstrually?
___Are your pupils usually dilated and large?
___Do you have difficulty falling asleep at night?
___Do you experience heartburn or wake up with a bitter taste in your mouth?
___Are your menses painful?
___Do you feel premenstrual cramps in the area of the external genital area?
___Is your menstrual blood thick and dark or purplish in color?
___Is your tongue dark or purplish in color?
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HEART DEFICIENCY
___Do you wake up in the early morning and have difficulty getting back to sleep?
___Do you have heart palpitations (pounding or racing heart), especially when anxious?
___Do you have nightmares?
___Do you seem low in spirit or lacking in vitality?
___Are you prone to agitation or extreme restlessness?
___Do you fidgit?
___Is the tip of your tongue red?
___Is there a crack in the center of your tongue that extends nearly to the tip?
___Do you sweat excessively, especially on your chest?
EXCESS HEAT
___Is your pulse rapid or do you feel your heart rate is rapid?
___Are your mouth and throat usually dry?
___Are you thirsty for cold drinks most of the time?
___Do you often feel warmer than those around you?
___Do you wake up sweating or have hot flashes?
___Do you break out with red acne (especially premenstrually)?
___Do you have a short menstrual cycle?
___Do you have vaginal irritation or rashes?
DAMPNESS
___Do you feel tired or sluggish after a meal?
___Do you have fibrocystic breasts?
___Do you have cystic or pustular acne?
___Do you have urgent or foul-smelling stools?
___Does your menstrual blood contain stringy tissue or mucus?
___Are you prone to yeast infections and vaginal itching?
___Do your joints ache, especially with movement?
___Are you overweight?
___Do you have a wet, slimy tongue?
DAMP HEAT
(Signs of heat plus damp)
___Do you have foul-smelling, yellow or greenish vaginal discharge?
___Are you prone to vaginal/rectal itching during the 2nd half of your cycle or just before
menses?
COLD UTERUS
(signs of KI Yang deficiency plus blood stasis)
___Does your lower abdomen feel cooler to the touch than the rest of your trunk?