Women only:
Women or Men:
1. Are you pregnant now?
□ Yes
□ No
Urine is:
□ Normal color
2. Are you nursing?
□ Yes
□ No
3. Number of children:______
4. Age of first period:__________
5. Age of menopause if
applicable:________________
6. Is your menses cycle regular?
□ Yes
□ No
a. Average number of days in flow:____
b. The flow is:
□ Normal
□ Heavy
c. The color is:
□ red
□ dark
□ Dark yellow
□ Cloudy
□ Bad odor
□ Burning
□ Difficult
□ Clear
□ Reddish
□ Scanty
□ Frequent
□ Painful
□ Urgent
Bowel movements are:
□ Loose
□ Normal consistency
□ Dry
□ Daily
□ Irregular frequency
□ other_______________
□ Light
□ purple
□ light brown □ brown
d. Do you have the following menstruation
related symptoms?
□ Blood clots
□ Cramps
□ Nausea
□ Breast distension
□ PMS
□ Bleeding between periods
□ Heavy vaginal discharge between periods
e. Type of Birth
control:_______________________
Men Only:
□ Discharge
□ Pain or swelling of testicles
□ Ejaculatory problems
□ Impotence/erectile dysfunction
□ Prostate problems
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Check all symptoms you are presently experiencing:
Lung&Large Intestine Meridian/Organ Network
__allergies
__frontal sinus headache
__arm/wrist/elbow pain
__shoulder pain
__asthma/bronchitis
__pneumonia
__constipation
__loose stools
__irritable bowel
__coughing/sneezing
__wheezing/short of breath __eczema/psoriasis/rash
__frequent colds
__sinusitis
__weak voice
__other_________
__smell problems
__stiff joints/neck
__lethargy/fatigue
__flatulence
__mucus
__nasal problems
__sadness/grief
Kidney&Bladder Meridian/Organ Network
__adrenal weakness
__hot flashes
__hip/knee pain
__impotence/low libido
__bladder infections
__Infertility/sterility
__brittle bones
__hair loss
__cold hands/feet
__night sweats
__dark/puffy eye area
__poor memory
__depression/fear
__premature grey hair
__sciatica/back pain
__ringing in ears
__kidney stones
__edema/water retention
__lethargy/fatigue
__urine incontinence
__other________
Liver&Gallbladder Meridian/Organ Network
__anger/irritability
__headaches/migraines
__breast tenderness
__hemorrhoids
__brittle/ridged nails
__gallstones
__flatulence
__irritable bowel
__depression
__indigestion
__pain in sides
__blood shot/dry eyes
__vision problems
__bitter taste in mouth
__PMS
__nausea/vomiting
__stiff neck/shoulders
__tension/cramps
__menstrual problems
__seizures/convulsions
__other__________
Heart&Small Intestine Meridian/Organ Network
__abdominal pain
__hot flashes
__angina
__restlessness
__anxiety/dread
__lack of joy
__indigestion
__hearing problems
__neck pain
__elbow/shoulder pain
__heart problems
__palpitations
__sleep problems
__tongue/speech problem
__poor circulation
__upper back pain
__wrist pain
__other__________
Spleen&Stomach Meridian/Organ Network
__abdominal pain
__distention/bloating
__aching/heavy limbs
__headaches
__poor memory
__difficult focusing
__appetite problems
__ belching
__colic/indigestion
__loose stools
__irritable bowel
__stomach ulcer
__sweating
__lethargy/fatigue
__organ prolapse
__other___________
__muscles weak
__nausea/vomiting
__worry/overthinking
__hiccups
__hemorrhoids
__anemia
__bruise easily
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