Name: Today s Date: Yes No Men Only Answer the following Male questions [ ] [ ] Do you get spontaneous sexual emissions or premature ejaculations?
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1 Robert Lloyd McDonald R.TCMP R.Ac.. & Associates Crown Steel Drive Markham, ON L3R 9X clinic fax Chinese Medicine detailed questionnaire Name: Today s Date: Yes No Both Male and Female (Kid Yin Vacuity) [ ] [ ] Do you hair loss or thinning of your hair? [ ] [ ] Do you have loose teeth? [ ] [ ] Do you have a loss of hearing? [ ] [ ] Do you have soreness or weakness of the lower back? [ ] [ ] Do you have soreness or weakness of the knees? [ ] [ ] Do you get ringing in the ears (tinnitus)? [ ] [ ] Do you get light headed or dizzy easily? [ ] [ ] Do you get dark circles under your eyes? [ ] [ ] Are you prone to hot flashes? [ ] [ ] Do you get a surge of heat during the afternoon or evening? [ ] [ ] Do you get a sore throat often or easily? [ ] [ ] Do you get a dry mouth often? Or are you thirsty often? [ ] [ ] Does the palms of your hands or soles of your feet get red easily? [ ] [ ] Do you consider yourself hyper sensitive? [ ] [ ] Do you have low libido? [ ] [ ] Do you get vaginal dryness? [ ] [ ] Do you have painful intercourse due to lack of vaginal secretions? [ ] [ ] Is your mid-cycle cervical mucous scanty or missing? Yes No Men Only Answer the following Male questions [ ] [ ] Do you get spontaneous sexual emissions or premature ejaculations? Yes No Both Male and Female (Kid Yang Vacuity) [ ] [ ] Would you describe yourself as being afraid, frightened or startled easily? [ ] [ ] Do you get cold hands or feet often? [ ] [ ] Do you get cold easily? [ ] [ ] Do you have an adversity (strong dislike) for cold weather? [ ] [ ] Do you urinate frequently? [ ] [ ] Do you get a lot of clear urine that is in a large volume? [ ] [ ] Do you wake up at night to urinate? If so how many times: [ ] [ ] Do you have urgent bowels movements first thing in the morning?
2 [ ] [ ] Do you have pre-menstrual lower back pain? [ ] [ ] Do you have profuse white or clear vaginal secretions (discharge)? [ ] [ ] Does your menstrual blood tend to be dull (not bright) in colour? [ ] [ ] Do you feel cold cramps during your period that respond well to heat? Yes No Both Male and Female (Spleen Vacuity) [ ] [ ] Are you often tired? [ ] [ ] Do you have a poor appetite? [ ] [ ] After a meal do you feel tired or want to sleep? [ ] [ ] Do you feel bloated after eating a meal? [ ] [ ] Do you crave sweets? [ ] [ ] Do you get loose stool or diarrhea often? [ ] [ ] Do you get abdominal pain often? [ ] [ ] Do you have difficulty digesting certain foods? If so what: [ ] [ ] Do you get a cold nose easily? [ ] [ ] Are you prone to feeling heaviness of your body? Is so where: [ ] [ ] Are you prone to feeling as if your brain is in a fog? [ ] [ ] Do you bruise easily? [ ] [ ] Do you think you have poor circulation? [ ] [ ] Do you have varicose veins? [ ] [ ] Are you lacking strength in your arms or legs? [ ] [ ] Are you lacking in exercise? [ ] [ ] Are you prone to worry or over thinking / analyzing? [ ] [ ] Have you been diagnosed with low blood pressure? [ ] [ ] Do you sweat a lot without exerting yourself? [ ] [ ] When you stand up quickly do you get dizzy, light headed or see spots? [ ] [ ] Do you get sick often? [ ] [ ] Have you been diagnosed with a low thyroid? (hypothyroid) [ ] [ ] Have you been diagnosed with anemia? [ ] [ ] Do you think your complexion is pale? Or Pale yellowish? [ ] [ ] Do you have hemorrhoids? Any history of polyps? [ ] [ ] Is your menstruation thin, watery, profuse, or pinkish in colour? [ ] [ ] Are you more tired around ovulation or menstruation? [ ] [ ] Do you ever spot a few days or more before your period comes? [ ] [ ] Have you ever been diagnosed with uterine prolapse? [ ] [ ] During your period do you get a bearing down sensation in your uterus? Yes No Both Male and Female (Blood Vacuity) [ ] [ ] Do you have dry skin? [ ] [ ] Are you prone to getting chapped lips? [ ] [ ] Are your fingernails or toenails brittle?
3 [ ] [ ] Are you losing hair on your head? [ ] [ ] Is your hair dry, brittle or with split ends? [ ] [ ] Do you have diminished night time vision? [ ] [ ] Are your lips or the inner side of your eye lids pale in colour? [ ] [ ] Do you get dizzy or light headed around your period? [ ] [ ] Do you get night sweats before your period? [ ] [ ] Are your menses scanty and or late? Yes No Both Male and Female (Blood Stagnation) [ ] [ ] Do you experience periodic numbness of your hands and feet? [ ] [ ] Do you have varicose or spider veins? [ ] [ ] Do you have red hemangiomas (cherry red spots) on your skin? [ ] [ ] Does your complexion appear dark or sooty? [ ] [ ] Do you have dark spots in your eyes? [ ] [ ] Have you been diagnosed with any vascular problems or blood clotting? [ ] [ ] Do you get cramps or pain at night or in the evening in the same location? [ ] [ ] Is your menstrual flow ever dark red, brown or black in colour? [ ] [ ] Do you experience mid cycle pain around your ovaries? [ ] [ ] Do you have painful, unmovable breast lumps? [ ] [ ] Do you have piercing or stabbing menstrual cramps? [ ] [ ] Does your menstrual blood contain clots? [ ] [ ] Have you ever been diagnosed with endometriosis or uterine fibroids? [ ] [ ] Is your lower abdomen tender to palpation (resists touch)? [ ] [ ] Can you feel any abnormal lumps in your lower abdomen? Yes No Both Male and Female (Liver Depression Qi Stagnation) [ ] [ ] Are you prone to emotional depression? [ ] [ ] Are you prone to irritability, anger and or rage? [ ] [ ] Do you suffer from moodiness / mood swings / feelings of frustration? [ ] [ ] Do you have difficulty falling asleep at night? [ ] [ ] Do you experience heart burn? [ ] [ ] Do you wake up with a bitter taste in your mouth? [ ] [ ] Do you get distension or fullness in your abdomen? [ ] [ ] Do you suffer from excess tension? [ ] [ ] Do you get muscle spasms, cramps or twitches? [ ] [ ] Do you get pain / tightness / aching of the diaphragm or lower rib cage? [ ] [ ] Do you get gas pains, tension in the stomach or intestines (bowls)? [ ] [ ] Do you get brittle or ridged nails? [ ] [ ] Do you get a lot of rectal gas? [ ] [ ] Do you feel unfinished after taking a bowl movement? [ ] [ ] Do you lack a sense of direction in your life?
4 [ ] [ ] When pre-menstrual do you get irritable? [ ] [ ] Do you feel irritable around ovulation? [ ] [ ] Does it feel like your ovulation lasts longer than it should? [ ] [ ] Are your breasts sensitive, sore, or tender at ovulation? [ ] [ ] Do you experience nipple pain or discharge? [ ] [ ] Do you have a lot of pre-menstrual breast distension or pain? [ ] [ ] When pre-menstrual, do you become bloated? [ ] [ ] Are your menses painful? [ ] [ ] Do you feel your menstrual cramps in the external genitalia? [ ] [ ] Is the menstrual blood thick and dark, or purplish in colour? Yes No Both Male and Female (Shen Disturbance) [ ] [ ] Do you have difficulty falling asleep? [ ] [ ] Do you wake up frequently at night? [ ] [ ] Do you wake up and trouble falling back to sleep? [ ] [ ] Do you feel your heart beating in your chest, especially when anxious? [ ] [ ] Do you have nightmares? [ ] [ ] Do you seem low in spirit or lacking vitality? [ ] [ ] Are you prone to agitation or restlessness? [ ] [ ] Do you get fidgety? [ ] [ ] Do you get easily moved to tears? [ ] [ ] Do you always feel like you need more sleep? [ ] [ ] During sleep do you get vivid or active dreams? [ ] [ ] Do you get anxious a lot? [ ] [ ] Do you have poor memory? [ ] [ ] Do you get easily confused or disoriented? [ ] [ ] Do you have trouble finding the right words? [ ] [ ] Do you find that you laugh to easy or laugh for no reason? [ ] [ ] Do you get dullness of thought? [ ] [ ] Do you perspire or get flushed easily when excited? [ ] [ ] When nervous do you get frequent urination or bowel movements? Yes No Both Male and Female (Internal Heat) [ ] [ ] 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 get sores on your tongue or mouth? [ ] [ ] Do your gums bleed easily? [ ] [ ] Do you get red eyes? [ ] [ ] Do you break out with red acne? Is it worse pre-menstrual: Yes/No [ ] [ ] Do you have a short menstrual cycle? [ ] [ ] Is your menstrual flow heavy?
5 [ ] [ ] Do you have vaginal irritation or rashes? Yes No Both Male and Female (Internal Dampness) [ ] [ ] Do you feel tired and sluggish after a meal? [ ] [ ] Do you have cystic or pustular acne? [ ] [ ] Do you have urgent, bright, or foul smelling stools? [ ] [ ] Do your joints ache and feel heavy, especially with movement? [ ] [ ] Do you have fibrocystic breasts? [ ] [ ] Does your menstrual blood contain stringy tissue or mucous? [ ] [ ] Are you prone to yeast infections and or vaginal itching? Yes No Both Male and Female (Damp Heat) [ ] [ ] Do you have red sores around your genitalia? [ ] [ ] Do you often find your bowel movements are offensive smelling? [ ] [ ] Do you get boils or carbuncles? [ ] [ ] Do you suffer from rectal itching? [ ] [ ] Do you get weeping in your rectal area? [ ] [ ] Do you get itching and lesions on your skin? Do they weep: Yes/No [ ] [ ] Do you have foul smelling vaginal discharge? [ ] [ ] Do you get yellow or greenish vaginal discharge? [ ] [ ] Are you prone to vaginal or rectal pre-menstrual itching?
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