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
__________________________________________
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
__________________________________________
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_______________________________
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