Temperature - Do you:  
Tend to feel hot/warm Have deep heat in your body
Tend to feel cold/cool Have recurrent fevers
Have a low grade fever all of the time Have recurrent chills
Have a low grade fever in the evening Have cold hands
Feel warmer in the afternoon or evening Have cold feet
Have heat or warmth in your  palms Have chilly arms
Have heat or warmth in your soles Have chilly legs
Have heat or warmth in your lower back Have cold in your lower back

 

Sleep - Do you:  
Have difficulty going to sleep Have difficulty awakening in the AM
Awaken during the night Feel tired or sleepy during the day
Have difficulty returning to sleep Need to take naps
Sleep shallowly Feel "wired and tired"
Have dreams disturb your sleep Get a "second wind" at night

 

Exercise & Energy
How much exercise do you get weekly?
Are your symptoms and signs?   
better with exercise  worse with exercise  the same
How is your general energy level?  Sufficient  Too Much  Too Little      
How is your energy level after eating?  Same  Increased  Decreased

 

Appetite - Do you:
Have a         poor  good  excessive  constant    appetite
Crave these tastes       salty  sour,  bitter  sweet  spicy
Avoid these tastes       salty  sour,  bitter  sweet  spicy

 

Digestion  - Do you:  
Have regular meals Have abdominal pain or cramping
Taste your food Have problematic bad breath
Have a "noisy" stomach Have flatulence
Have indigestion Have belching
Feel like your abdomen is bloated Have nausea
Have sour regurgitation or belching Have vomiting
Have stomach pain or cramping  

 

Stools - Do you:  
Tend toward constipation Notice blood in your stools
Tend toward loose stools Notice blood on your stools
Have hard stools Notice a foul or repugnant odor from your stools
Have soft stools Notice a mucus-like substance in or
on your stools
Have diarrhea often Notice "coffee grounds" in your stools
Notice undigested food in your 
stools
 
What color are your stools
Number of daily bowel movements

 

   
Urine - Do You:  
Awaken at night to urinate Notice "cloudiness" in your urine
Have an urgent feeling when you have to urinate Notice a "milky" quality to urine
Have difficulty starting urination Notice "sand" in your urin3
Have starting and stopping flow Notice blood in your urine
Have a weak flow Have strong-smelling urine
Have pain when you urinate Have urinary tract infections  
Notice "mistiness" in your urine  
What color is your urine (w/o vitamins)
How often do you urinate in a day
   

 

Reproduction  
Have low sexual energy Experience impotence
Have excessive sexual energy Have itching in/on your genitals
Have pain during sex Have pain in your genitals
Have premature ejaculation Have an odor from your genitals?
Have seminal emission  
Have a genital discharge? What color?
How often do you engage in sex
 
Reproduction - Women 
Are you pregnant now or have reason to believe you are
cramps during your menstrual flow
Are the cramps somewhat painful
Are the cramps very painful
Are there clots in your menstrual flow    few clots       many clots
How long is your menstrual cycle days
Is it regular  
How long is your menstrual flow
What color is your menstrual flow
Do You use birth control pills? How long?
How many pregnancies have you had
How many children have you borne
How many miscarriages
How many abortions

Respiration Do You have:
 
Have shortness of breath on slight exertion colored phlegm
Shortness of breath - worse when lying down small amounts of phlegm
Difficulty inhaling large amounts of  phlegm
Difficulty exhaling difficulty coughing phlegm up
Sneezing Sinus congestion
A cough         dry   wet Sinus infections

 

Pain - Do You Have:  
Rapid onset Burning pain
Gradual onset Stabbing pain
Fixed location pain Joint pain
Shifting location pain Low back pain
Dull pain Chest pain
Sharp pain Pain under the ribs

Headaches           Frontal  Side  Back  Behind the eyes

Head to Toes

Eyes - Do you have:

Ears - Do you:

change in vision Have difficulty hearing
blurry vision Have noise in your ears 
High-pitched  Low-pitched
red eyes
dry eyes Have ear pain
gritty eyes Feel pressure in your ears
poor night vision Have discharges from your ears
See floaters  
 

Mouth - Do you have:

Tongue ulcers Bitter taste in your mouth
Bleeding gums Other tastes in your mouth
 

Teeth

What is the condition of your teeth. 
   
Do you have tooth pain
   

Throat - Do you have:

Nose - Do you have:

mild sore throats often obstructed nose
Difficulty swallowing nosebleeds
Sensation of something in your throat dry nose
Phlegm in your throat
 

Muscles - Do you have:

Muscle weakness Where

Muscle tension Where

Muscle aches

Muscle tics

Muscle cramps   Muscle spasms
 
Emotional/Mental/Thinking - Do you have:
Have poor memory Have difficulty concentrating
Have mental restlessness any stressful experiences.
Are any of these emotions predominant
Fear  Anger  Joy  Shock  Worry  Sadness
 

Miscellaneous - Do you:

Feel your heart beat Have thirst without a desire to drink
Have dizziness Have rashes
Have brittle nails Have itching
Have a feeling of heaviness     Body  Head  Arms   Legs

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