Fertility Questionnaire

Chinese Medicine
Diagnostic
Women's Questionnaire

Chinese Medicine Women's Health Questionnaire
Identify your Chinese medicine constitutional type, the imbalances hindering you, and how to fix them
using our FREE women's health & fertility questionnaire!
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name

CHINESE MEDICINE DIAGNOSTIC WOMEN'S HEALTH QUESTIONNAIRE

This unique questionnaire has been designed to
inspire you to understand your body at a deeper level
and boost your health and fertility!

It aims to help you:

✅ Increase awareness of your body, and become more sensitive to subtle symptoms, signs, and changes occurring during the menstrual cycle.
✅ Pinpoint the most appropriate treatments for you, including acupressure, aromatherapy, food supplements and individually tailored nutrition.
✅ Identify your main imbalances from a Chinese medical point of view and correlate them with biomedical problems.

➡️ After completing the questionnaire, you will receive an email with an explanation of your results that includes important nutritional tips to help you achieve and maintain optimum balance.

This one-of-a-kind offering is given to you completely free of charge by Ilaira Bouratinos, internationally renowned expert in fertility and Traditional Chinese Medicine, with over 30 years clinical experience.

Name

First NameLast Name

About the Chinese Medicine Fertility Questionnaire

In Chinese medicine, a diagnosis is reached via a "differentiation" or "investigation" of syndromes 辨证. A syndrome is a collection of symptoms and physical signs that together form a pattern of disharmony.

The purpose of this questionnaire is to pinpoint the predominant syndromes which are the root cause of infertility, and to provide you with specific health inducing guidelines to target the main things you need to work on in order to correct your underlying imbalances.

After determining your main syndromes (the underlying causes) via the questionaire's unique scoring system, you will be able to use the ensuing recommendations to bring your body back to a state of health and balance.

About the Chinese Medicine Fertility Questionnaire

What's more, whilst going through the questionnaire, it also becomes quite apparent that the underlying infertility syndromes include many symptoms and signs that relate to health imbalances in other areas, besides the reproductive system. Consequently, correcting these imbalances using the ensuing instructions, will have profound effects on your entire health, and you will see positive changes in areas you may have thought were completely unrelated!

After determining your main syndromes (the underlying causes) via the questionaire's cleverly designed scoring system, you will be able to use the recommended self help methods to help correct them, and bring your body back to a state of health and balance.

The methods presented include:

- Nutrition tailored for the particular imbalance(s)
- Nutrition to support each phase of the cycle
- Food supplements, vitamins and herbs for boosting fertility
- Acupressure - targeted use of self-administered treatment on specific acupuncure points
- Self massage and essential oils for fertility
- Targeted exercises, meditations and visualisations
- Specific lifestyle changes

If you haven't applied for the workshop yet, you can do so here.

While going through this questionnaire, it will become apparent that the underlying infertility syndromes include many symptoms and signs that relate to health imbalances in other areas apart from the reproductive system. As a result, correcting these imbalances, using the ensuing instructions, will have profound effects on your overall health, and you will see positive changes in areas you may have thought were completely unrelated!

The Proposed Self-help Treatments include:

- Nutrition tailored for the particular imbalance(s)
- Nutrition to support each phase of the cycle
- Food supplements, vitamins and herbs for boosting fertility
- Acupressure - targeted use of self-administered treatment on specific acupuncture points
- Fertility boosting self-massage
- Essential oil usage
- Targeted exercises, meditations and visualisations
- Recommendations for specific lifestyle changes

If you haven't applied for the workshop yet, book now to secure to secure the Early Bird discount.

The questionnaire consists of 9 categories. Each category relates to a Traditional Chinese Medicine (TCM) syndrome.

A syndrome is a collection of symptoms and signs which together make up a "pattern of disharmony". These patterns of disharmony are also usually inextricably connected to your constitution.

Within each category (syndrome) there are questions relating to the following areas of enquiry:

Face & Tongue, General, Digestive, Psychoemotional, Gynecological (Menstruation, Vulva & Discharge, Sex), Medical.

Scoring method:

ANSWER	SCORE
NO (N/A)*	0 points
SOMETIMES	0.5 points
YES (USUALLY)	1 point
EXTREME**	2 points

*When the answer to a question is "No", it is not necessary to select the "No" button – just leave it blank.

**Only choose the "Extreme" option if your symptom is very pronounced, but only up to four times in each section and up to 12 times in the entire questionnaire.

When you have finished filling out your answers your score will be calculated as a percentage. After submitting your form, you will receive an email indicating your highest scoring syndrome with important nutritional tips to help you achieve and maintain optimum balance.

NOTE

When you enrol on our boosting fertility course you will be able to see all your scores and get access to all the treatment recommendations, via on-demand video and live zoom sessions for even more personalised guidance. After you submit your form you will receive information on how to enrol.

➡️ Treatments are mostly targeted to your three highest scoring syndromes (categories). Scores of less than 33% are not generally considered important.

To receive your Chinese medicine results and nutritional tips, please enter and verify your email address (in the next field).

Name*
Email*
Country*
Country*
We value your privacy. We are in compliance with the General Data Protection Regulation (GDPR). We NEVER share your data. PERIOD.

Communication with you via email

Score 1 Percent
Score 2 Percent
Score 3 Percent
Score 4 Percent
Score 5 Percent
Score 6 Percent
Score 7 Percent
Score 8 Percent
Score 9 Percent
Category Maximum Score
Section highest percentage
Section with highest percentage

Internal Language
Use this field as the condition for autoresponder emails
Should be Empty:

	No	Sometimes	Yes	Extreme
Do you have red cheeks? Red blotches, patches?
Do you have circles around your eyes (they can be dark, reddish or brownish)?
Do you have thread veins on your face?
Is your skin dry and sensitive?
Is your tongue red?
Is your tongue dry?
Does your tongue have cracks on it?
Do you have lower back weakness, soreness or pain?
Do your knees feel weak or painful?
Do you have ringing in your ears?
Is your hair prematurely grey?
Do you tend to feel warm or hot, more than the people around you?
Do you have night sweats?
Are you prone to hot flashes, particularly before your period?
Do you often feel thirsty?
Is your urine yellow or darkish (without taking vitamin B)?
Are you generally restless?
Do you find it difficult to relax?
Do you have difficulty falling asleep?
Do you feel exhausted or worn out?
Do you suffer from dizziness?
Do you fidget a lot?
Do you often feel fearful?
Do you suffer from anxiety?
Do you have painful periods?
If so, is the pain like a dull ache?
Does it extend to the lower back?
Is your menstrual blood thin?
Is your menstrual blood a light red colour?
Does your period start off with pale pink discharge?
Do your periods come early, a cycle of 26 days or less?
Do your periods last 4 days or less?
Difficulty noticing fertile cervical mucus and if you do notice it is little?
Do you have vaginal dryness?
Do you often feel your vulva itchy or sore?
If so is it often after sex or during the next day(s)?
Do you have pain during sex?
Do you get cystitis/burning urination immediately after or on the days following sex?
Do you have high libido?
Do you feel dissatisfied after sex?
Have you been diagnosed with low estrogen levels?
Have you been diagnosed with low progesterone levels or luteal phase defect?
Have you been diagnosed with low AMH or high FSH?
Have you been diagnosed with a low TSH or high thyroid hormone levels?
Have you been diagnosed with vaginal or uterine infections or endometritis?

	No	Sometimes	Yes	Extreme
Is your face pale or whitish (do you use a lot of blusher)?
Is your under eye area puffy or swollen, especially/worse in the morning?
Does your face appear puffy or swollen?
Is your tongue pale or white?
Is your tongue swollen?
Is your tongue quite wet?
Are you typically colder than those around you?
Are your feet cold, especially at night?
Is your lower back sore, achy or weak?
Do you have a tendency for water retention and / or swelling, especially in your lower body, legs and feet?
Does your body feel heavy or weak, especially your lower limbs, back and abdomen?
Do your knees ache?
Do you have a tendency to put on weight?
Do often catch cold?
Do you have sweaty or clammy skin?
Do you wake up to urinate at night or early in the morning?
Do you urinate frequently, and is the urine diluted (like plain water)?
Do you need to urgently defecate or have loose stools or diarrhoea in the morning?
Do you feel drowsy or sleepy a lot of the time?
Do you sleep deeply?
Do you feel you never get enough sleep or permanently low in energy, tired and exhausted?
Do you feel fearful?
Do you feel down and depressed?
Are you frequently forgetful?
Do you have lower back pain premenstrually or during your period?
If so is it a dull aching pain?
Does your menstrual blood tend to be dull or pale in color?
Do you feel cold cramps during your period that improve with heat application?
Do you feel shivery during your period?
Do your periods last longer than 5 days?
Are your periods excessively heavy?
Do you usually have a long cycle, 30 days or more?
Is your ovulation usually painless?
Do you have profuse and / or white vaginal discharge?
Do you find it hard to notice your clear stretchy fertile cervical mucus?
Does your discharge smell “fishy"?
Do you often get thrush / candida?
Do you have low libido? Would rather go to sleep instead of having sex?
Do you have difficulty or inability to reach orgasm?
Is your estrogen level high?
Have you been diagnosed with low progesterone or luteal phase defect?
Have you been diagnosed with high TSH or low thyroid hormone levels (hypothyroidism)?
Have you been diagnosed with a B-12 deficiency?
Is your vitamin D level below the minimum level or on the low side?
Is your prolactin level higher than normal, or on the high side?
Have you been diagnosed with PCOS, uterine fibroids or ovarian cysts?

	No	Sometimes	Yes	Extreme
Is your face generally pale? If you do wear makeup do you use a lot of blusher?
Are your lips pale and / or dry?
Is your tongue swollen? Does your tongue feel like its “very large” or as if it is taking up a lot of space in your mouth?
Does your tongue have a scalloped appearance? (teeth marks on your tongue)
Do you feel tired or exhausted a lot / all of the time?
Are you prone to feeling heavy or sluggish?
Are you lacking strength in your arms and legs?
Do you bruise easily / often?
Do you have varicose veins?
After a meal do you feel drowsy? Is your energy lower?
Do you feel bloated after eating?
Do certain foods make you feel bloated (e.g. green vegetables, cabbage, gluten)?
Do you have a lot of food cravings?
Do you generally crave carbohydrates and starchy foods?
Do you crave sweets, especially before your period?
Do you have loose stools or ever see undigested food in your stools?
Does your abdomen often feel painful?
Do you urinate often?
Is your urine pale or transparent?
Do you have haemorrhoids?
Do you suffer from water retention?
Do you have cellulite?
Are you overweight or do you have a tendency to put on weight easily?
Does your belly stick out or do you sometimes look pregnant?
Do you find it difficult concentrating? Do you have difficulty memorising information?
Are you prone to worry and anxiety?
Do you feel exceptionally tired or exhausted around menstruation?
Is your period very heavy?
Does you period last for 5-6 days or longer?
Does your menstruation drag on with spotting?
Is your menstruation thin and watery, or light red in color?
Do you ever see spotting a few days before your period or during ovulation?
Are your menstrual cramps accompanied by a bearing-down or pulling sensation in your uterus?
Do your breasts feel swollen before and / or during your period?
Is your cycle longer than 30 days or shorter than 26 days, or irregular?
Do you have a lot of chronic vaginal discharge (creamy or white)?
Is your libido generally low?
Do you find it hard to notice your fertile cervical mucus?
Have you been diagnosed with low progesterone or luteal phase defect?
Have you been diagnosed with a high TSH or low thyroid hormone levels (hypothyroidism)?
Have you been diagnosed with a B-12 deficiency?
Is your vitamin D deficient or on the low side?
Have you ever been diagnosed with PCOS, uterine fibroids or ovarian cysts?
Have you ever been diagnosed with uterine prolapse?
Have you been diagnosed with anemia, ferritin or iron deficiency?

	No	Sometimes	Yes	Extreme
Does your face often look pale or sallow?
Do you have very dry skin? Do you use large amounts of moisturiser?
Do you have flaky skin?
Are you prone to getting chapped lips?
Are you prone to a lot of wrinkles and lines on your face?
Is your tongue dry?
Is your tongue pale? Even paler at the edges/sides?
Are your fingernails or toenails thin or brittle? Do they break easily?
Is your hair very thin, brittle or dry?
Does your hair fall out easily, recently or long term?
Do you get numbness or tingling in your limbs?
Do you suffer from cramps in your legs or elsewhere in your body?
Do you feel stiff and generally lack flexibility in your body?
Do you suffer from dull headaches?
Is your skin extremely dry on your body?
Do you suffer from dizziness or light-headedness?
Do you feel dizzy or have visual changes when you stand up fast?
Do you have diminished nighttime vision?
Do your eyes feel uncomfortable in bright light (photophobia)? Do you wear sunglasses all / a lot of the time?
Do you see “floaters” in your field of vision?
Do your eyes often feel dry?
Do you suffer from constipation?
Are your stools generally dry?
Do you have difficulty sleeping?
Do you wake up with the slightest noise?
Do you get startled easily?
Do you feel your heart beating intensely (palpitations)?
Do you feel your heart beating stronger (palpitations) while you're lying down or resting?
Do you have light menstrual flow (hypomenorrhoea)?
Do your periods last for 3 days or less (hypomenorrhoea)?
Are your periods late? Is your cycle longer than 30 days? (oligomenorrhoea)
Do you have light brown flow (possibly like coffee grounds) at the beginning and / or at the end of your period?
Is your cycle irregular?
Do you have menstrual pain towards the end of your period (but not so much at the beginning)?
Do you have headaches before / during your period?
Do feel more tired or exhausted after your period?
Are you unable to notice clear, stretchy, fertile cervical mucus? Is your cervical mucus very scant?
Is your vagina generally dry?
Do you have pain during sex?
Have you been diagnosed with low estrogen levels?
Have you been diagnosed with low AMH levels?
Have you been diagnosed with anemia or iron deficiency?
Is your vitamin D deficient or on the low side?
Have you been diagnosed with vitamin B12 deficiency?
Have you been diagnosed with magnesium deficiency?

	No	Sometimes	Yes	Extreme
Does your complexion appear dark and “sooty"?
Do you tend to have areas of darker skin, blotches or patches on your face?
Are there dark or excessively large or distended veins under your tongue?
Does your tongue have a dark or purplish hue? Or dark spots / areas?
Do you sometimes experience numbness of your hands and feet (especially at night)?
Do you have visible dark or purple thread veins on your face?
Do you have varicose veins?
Do you have aches and pains in general?
Do you have hemorrhoids?
Is your lower abdomen tender on palpation (touch)?
Can you feel any hard or painful lumps in your abdomen?
Do you feel irritated or angry, more so premenstrually?
Do you feel dark and gloomy?
Do you sometimes have violent thoughts or dreams, especially premenstrually?
Are you prone to drinking a lot of alcohol, especially before or during you period?
Are you prone to obsessive behaviour?
Do you have PMS with abdominal pain and / or breast pain?
Is your period excessively heavy? Do you ever have flooding?
Is your menstrual blood dark red or purple, or ever brown or black in color?
Does your menstrual blood contain large clots?
Are your periods extremely painful (piercing or stabbing menstrual cramping)?
Do you have intense menstrual cramps that subside after a clot has been passed?
Does the pain last for the duration of your period, including before the bleeding starts?
Does the pain get worse on the second or third day of your period?
Is the pain more intense at the centre of you belly (rather than the sides)?
Is the pain all over your belly (in the centre and sides)?
Do you have pain during ovulation?
Do you sometimes have intense pain during sex?
Do you sometimes bleed after sex?
Do you have chronically painful, breasts?
Do you have hard, fixed breast lumps?
Is your endometrium on the thick side or excessively thick (diagnosed via ultrasound)?
Have you ever had discharge from your nipples?
Have you ever been diagnosed with ovarian cysts?
Have you been diagnosed with high estrogen levels?
Have you been diagnosed with endometriosis or uterine fibroids?
Have you been diagnosed with uterine infections, inflammation, endometritis, salpingitis?
Have you been diagnosed with chronic pelvic inflammatory disease?
Have you been diagnosed with any vascular abnormality or blood clotting disorder?

	No	Sometimes	Yes	Extreme
Do you have furrows between your eyebrows or intense “11” lines and/or deep horizontal wrinkles/lines on your forehead?
Do you get spots or acne? Worse before your period?
Is your tongue swollen and /or redder at the sides?
Does your tongue have a purplish hue?
Do you have aches and pains in your body that come and go?
Do you have neck and/or shoulder or upper back pain or stiffness?
Do your hands and feet feel cold?
Do you generally suffer from headaches or migraines?
Do your eyes often feel tired, irritated or sore?
Do you (sometimes) have strong smelling body odour especially in your chest / underarm area? Particularly before your period?
Do you feel nauseous when you have your period, especially at the beginning?
Do you notice alterations between constipation and loose stools?
Do you get loose stools at the beginning of your period?
Do you often feel stressed and anxious?
Are you prone to irritability, anger and/or rage, particularly premenstrually?
Are you prone to mood swings, emotional depression or unhappiness, worse premenstrually?
Do you have a tendency to be hyperactive or overwork?
Do you have difficulty hearing what people are saying when there is background noise?
Do you have difficulty falling asleep at night? Do you stay up late usually?
Do you feel sluggish and / or grumpy after waking up?
Are you prone to obsessive behaviour?
Are you prone to drinking a lot of alcohol, especially before or during you period?
Do you often feel dissatisfied or disappointed with your life in general?
Do you have headaches or migraines before and/or during your period?
Do you have PMS with a lot of distension/bloating?
Are your breasts swollen and / or painful premenstrually?
Is your cycle irregular (varying in length)?
Do you have painful periods worse at the beginning (does the pain subside after a day or two, especially when the flow starts)?
Is the pain more at the sides of you belly, around your ovaries?
Does your menstrual pain decrease if you have been having regular sex?
Does your blood have small / medium size clots?
Is the blood darker at the beginning of your period and/or does your period start and / or finish with brown discharge?
Do you feel mid-cycle ovulation pain at the sides of your belly (around your ovaries)?
Do you feel bloated or irritable around ovulation?
Do you experience nipple pain?
Do your breasts feel lumpy sometimes (and at other times not so much)?
Does your libido pattern have a lot of ups and downs?
Do you often feel dissatisfied with sex?
Do you feel you can’t go to sleep without sex?
Have you ever been diagnosed with fibrocystic breast disease?
Have you ever been diagnosed with ovarian cysts?
Have you been diagnosed with high estrogen levels?
Have you been diagnosed with elevated prolactin levels?
Have you been diagnosed with endometriosis or uterine fibroids?

	No	Sometimes	Yes	Extreme
Is your complexion excessively excessively pale or excessively red?
Do you have red blotches on your face?
Is the tip of your tongue red or swollen? Are there red spots on the tip?
Is there a crack reaching the tip of your tongue?
Do you suffer from mouth ulcers?
Is your urine darkish usually?
Do you ever have a burning sensation on urination?
Do you sweat excessively?
Do you sweat with minimal exertion, especially on your chest?
Do you get short of breath easily?
Do you have heart palpitations?
Do you have a fast heart beat (more than 75 beats per minute)?
Have you ever had an irregular heartbeat?
Do you suffer from insomnia?
Do you have dream disturbed sleep or nightmares?
Do you wake up early in the morning and have trouble getting back to sleep?
Do you often suffer from anxiety or panic attacks?
Are you prone to agitation or extreme restlessness?
Do you feel low in spirit or lacking in vitality?
Are you often forgetful?
Do you feel tired after your period?
Is your menstrual blood thin and bright or light red?

	No	Sometimes	yes	Extreme
Do you tend to have a reddish complexion?
Do you have visible red thread veins, red patches, blotches or rashes on your face or body?
Does your face tend to feel hot?
Do you get red, inflamed spots / acne on our face (especially premenstrual)?
Do you get sores or ulcers in your mouth, tongue or lips?
Do your gums bleed easily / often?
Is your tongue quite/very red or magenta?
Does your tongue have red spots on it?
Does your tongue feel sore or painful?
Does your tongue have a yellow or brownish coating?
Do you generally feel hot?
Do you tend to sweat a lot? Do you wake up sweating?
Does your sweat tend to have a strong odour?
Do you have heart palpitations or a fast heartbeat?
Do you suffer from skin problems with redness and inflammation?
Do you have red hemangiomas (cherry-red spots) on your skin?
Are your mouth and throat usually dry?
Are you usually / often thirsty?
Do you desire cold or icy drinks most of the time?
Is your urine quite yellow, or darkish?
Do you suffer from constipation or hard, dry stools?
Do you suffer from diarrhoea? Do you sometimes have blood in your stools?
Do you suffer from insomnia?
Do you have vivid dreams? nightmares?
Are you prone to agitation or extreme restlessness?
Do you have a short menstrual cycle- 25 days or less?
Is your period excessively heavy? Do you sometimes flood?
Is your menstrual blood a (very) bright/intense red colour?
Do you suffer from genital irritation/inflammation?
Have you been diagnosed with excessively high or low oestrogen levels?
Have you been diagnosed with anaemia?
Have you been diagnosed with deficiency of thiamine (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6), folate (vitamin B9), cobalamin (vitamin B12) or iron deficiency?
Have you ever been diagnosed with an autoimmune condition?
Have you ever been diagnosed with dermatitis eczema psoriasis or other inflammatory skin conditions?
Have you been diagnosed with HIV, or venereal diseases?
Have you recently been diagnosed with an infectious disease?
Have you been diagnosed with hepatitis or other liver disease?
Have you been diagnosed with Crohn’s disease or another inflammatory bowel condition?

	No	Sometimes	Yes	Extreme
Do you have oily / greasy skin?
Do you get a lot of spots? Cystic or pustular acne?
Does your face appear puffy or swollen?
Are your eyes swollen, especially in the morning?
Do you have visibly open pores on your face?
Is your tongue swollen?
Does your tongue appear white or yellow?
Does your tongue have a thick or slippery/sticky coating?
Do you suffer from dull headaches?
Do you have a heavy sensation in your head?
Do you suffer from dizziness?
Do you suffer from water retention or swelling, worse premenstrually?
Do you have a lot of cellulite?
Do you have a tendency to put on weight easily? Are you overweight?
Is your skin usually clammy, sticky or sweaty?
Does your sweat have a strong odour?
Do you get short of breath easily?
Do you often suffer from coughing and/or phlegm?
Do your joints ache or feel stiff, especially in the morning?
Do carbohydrates make up a large proportion of your diet?
Do you consume a lot of sweet foods? Do you have sugar cravings?
Do you feel sleepy and sluggish, especially after eating?
Do you have indigestion, bloating, distension or gas, worse after eating?
Do you have a loose stools or diarrhoea sometimes/all the time?
Do you ever have mucous in your stools?
Do you have foul-smelling stools?
Is your urine cloudy?
Do you often feel heavy and sluggish?
Do you feel low in spirit or lacking in vitality?
Do you find it difficult concentrating?
Do you have a lot of [thick] vaginal discharge?
Does your menstrual blood contain stringy tissue or mucus?
Are you prone to fungal/yeast infections or vaginitis?
Do you have a genital itching or irritation?
Have you ever been diagnosed with vaginitis or candida?
Have you been diagnosed with ovarian cysts?
Have you been diagnosed fibrocystic breasts?
Have you ever been diagnosed with high prolactin or estrogen levels?
Have you ever been diagnosed with hypothyroidism?
Have you been diagnosed with lymphatic disorders?
Have you been diagnosed with chronic bacterial or fungal infections?
Have you been diagnosed with lipomas or cysts anywhere in your body?
Have you been diagnosed with hyperlipidaemia?
Have you ever been diagnosed with insulin resistance or high blood sugar?