Symptoms Form

Symptoms Form

Symptoms can change from time to time, so you will be asked to fill this out if I haven't treated you after sometime. Thank you for your additional time on this form.
Date*

MonthDayYear
Date
Hour Minutes
Client Name*

First NameLast Name
Please fill out any symptoms below:
Eyes:

Red/BurningPuffy/SecretionsDark CirclesDry/Red
Skin:

Red/Burning/InfectionsOily; rashes that ooze fluidPale; spontaneous sweatsDry/night sweats
Lungs

Loud cough; phlegm yellow/green)Productive cough/copious clearShortness of breath/wheezing; weakDry cough; chronic
Heart

Palpitations pounding; tachycardia (fast Heart Rate)Mental confusion; stifling (constrained/oppressed) sensationWeak circulation/bradycardia (Slow Heart Rate)Rapid beat; palpitations
Appetite:

Potentially excessiveLow; nauseaLowAppetite, only eats small amounts
Thirst

Can be strong, cold drinksLittle thirstPreference for warm drinksPreference for small frequent drinks
Bowels

Dry/hard stoolBurning diarrheaSticky; loose with mucousHypo-function; undigested foodDry stool; chronic constipation
Urine

Dark color, scant; acute UTICloudy; light colorLight in color; frequent at nightSlightly dark; scant; chronic UTI
Reproductive

Infections; prostatitisYeast infections; cystsLow LibidoHigh libido, dryness
Menses

Short Cycle; bright redYeast Infections; CystsLong or no cycle; light colorDark color, scant
Enegry

can be high; expressiveSluggishWeak; fatigueRestless; fidgety
Emotions

Anxiety, anger, maniaAbsent minded; cloudedWithdrawn/depressiveIrritable; anxious
Speech

Loud, rapid, talkativeSlow; affected by PhlegmSlow, weak, softRapid; not loud; nervous
Temperature

Fever; feels hot; sensitive to heatAlways cold; prefers warm clothesWarm in evening/at night
Sleep

Restless; difficult; dream disturbedSleepy; "foggy" head particular in AMCurls up; wants to sleep in.Wakes at night; night sweats.
Please list any other symptoms that may have not been listed in each category, Ex. Emotions:"I have mostly felt anxiety and not the others listed." Urine: just list what yours looks like currently if it doesn't fit. Thanks!!
Thank you for taking the time to fill this out! This information will help me understand how best to care for you.
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