PATIENT MEDICAL SYMPTOMS
Please check all symptoms that pertain to you at the current time.
 Anxiety
 Bleeding Gums
 Blood in Urine
 Burning Urination
 Cold Hands
 Crying Spells
 Dull Ache in Chest
 Fidgety
 Flushed Cheeks/Face
 Hot & Itchy Palms
 Insomnia
 Manic Behavior
 Mental Restlessness
 Night Sweats
 Palpitations
 Poor Memory
 Startles Easily
 Tendency to Scold People
 Tightness in Chest
 Tongue Ulcers
 Uncontrollable Laughter
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 Abundant Urination
 Burning Urination
 Dribbling Urine
 Early Morning Diarrhea
 Edema only in Feet & Legs
 Frequent Urination
 Insomnia
 Low Back Pain
 Low Sex Drive
 Night Sweats
 Premature Graying
 Ringing in Ears (Low or High Pitch)
 Wakes at Night to Urinate
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 Bad Breath
 Bloating/Abdominal Distention
 Bruise Easily
 Burning Sensation in Epigastrium
 Constantly Hungry
 Desire to curl up into a Ball
 Desire to only Drink Cold Liquids
 Pain after Eating
 Scanty, Clear Urine
 Tired After Eating
 Tired after Waking in the Morning
 Thirst with Desire to Drink Small Sips
 Undigested Food in Stools
 Weak Limbs
 Weak/Sore Knees
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 Blood-tinged Sputum
 Chronic Diarrhea
 Constipation
 Cough – Dry, or with Phlegm
 Dry Skin
 Easily Catch Colds
 Mucus and Blood in Stools
 Nasal Mucus – Green, or Yellow
 Reoccurring Sinus Congestion
 Runny Nose with Clear Mucus
 Shortness of Breath on Exertion
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 Alternating Constipation & Diarrhea
 Belching
 Depression
 Difficulty Making Decisions
 Dizziness
 Dull Yellow Eyes or Skin
 “Floaters” in Vision
 Headaches
 High Blood Pressure
 Irritability
 Migraines
 Moodiness
 Night Blindness
 Numbness or Tingling of Limbs
 Pain/Tightness around Ribs
 Rashes or Eczema
 Sensation of a Lump in the throat
 Sighing Often
 Tendency to have Angry Outbursts
 Thirst with No Desire to Drink
 Tremors or Shaking Limbs
Urine is:
□ Normal color
□ Dark yellow
□ Cloudy
□ Clear
□ Reddish
□ Scanty
Women only:
Men Only:
1. Are you pregnant now?
□ Yes
□ No
□ Discharge
2. Number of children:_________
□ Pain or swelling of testicles
3. Number of pregnancies:______
□ Ejaculatory problems
4. Age of first period:__________
□ Impotence/erectile dysfunction
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
□ Light
c. The color is:
□ red
□ dark
□ 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. Birth control:_______________________
Signature __________________________
Date_______________________________