Form - Dr Krupa Coaching

“Let food be thy medicine and medicine be thy food” – Hippocrates

Self-Assessment Health Profile

This profile can be used as an educational device as well as a diagnostic tool. It will aid you in becoming acquainted with the language of Chinese medicine.
Check the symptoms you have experienced during the last six months.
Circle and check those that have been most troublesome.

if you prefer to download the form and fill it out by hand – click here

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Slack Qi

perspires easily while at rest
atony or prolapse of stomach, intestines, anus
constant diarrhea or lack of bowel control
hemorrhoids, varicose veins
dizzy or weak after meal or bowel movement
well-being followed by sudden exhaustion

Slack Moisture

excess secretions: eyes, nose, mouth, skin, vagina
seminal incontinence, premature ejaculation
frequent urination or incontinence
dizzy or weak after sex

Slack Blood

easy bruising or bleeding
chronic ulcers: mouth, throat, stomach, intestines, vagina
excessive bleeding during menses, pregnancy, postpartum or menopause
bleeding hemorrhoids and blood in stool, urine, or sputum

Disturbed Shen

restlessness and agitation
hypersensitivity to pain or insult
sudden rage, grief or panic
constant anxiety, worry or confusion
easily startled or frightened
erratic sleep, insomnia or disturbing dreams
dull, glazed or bizarre look to eyes and face
delerium

Stagnant Qi

stuffy head
mild nausea or reflux
distension or fullness in chest or abdomen
gas pains, cramps, tension in stomach or intestines
hiccups, belching or flatulence
constipation or irregular bowel movements
dull or intermittent pains

Obstructed Qi

acute discomfort, fullness, pressure in head, chest, limbs or abdomen
abdominal bloating but unable to release gas
wheezing and chest pain
difficulty swallowing, as if something stuck
stitch or acute pain in abdomen, ribs, or flanksstitch or acute pain in abdomen, ribs, or flanks
fullness or dull pain under ribs or sternum

Stagnant Moisture

soft or loose stool
puffy eyes, face, hands or ankles
frequent, scanty or difficult urination
lethargic in humid weather
soft swellings, nodules, cysts, enlarged lymph nodes
premenstrual edema and swelling of breasts
tender muscles or joints
dry but thirsty

Obstructed Moisture

swollen or heavy head and limbs
swollen, sore muscles and joints
excess saliva, mucus or perspiration
scanty or absent urine
edema of hands, feet, face or abdomen
thick, nauseated feeling in mouth, stomach, head

Stagnant Blood

easy bruising
cold hands and feet
irregular or painful menses
mottling, numbing and chilling of limbs
sharp pains: head, eyes, joints, limbs, breasts, organs
mid-cycle or premenstrual pain or tender breasts
painful hemorrhoids, cysts or lumps

Heat

fever
pain, soreness, swelling or dryness with a sensation of heat or burning
sores or infections with green or yellow pus
yellow, green, or foul smelling discharge from ears, nose, throat, anus, vagina or urethra
extreme thirst with a craving for cold foods or drink
red eyes, ears, nose, lips, face, skin
feeling of heat: limbs, abdomen, chest, head, gentials
aggravation from alcohol, fried, or spicy foods, and heat environment

Cold

lack of thirst
listless and weak
cold feeling in limbs, head, chest, abdomen or genitals
pale face with cold, clammy hands and feet
loose stool after eating raw or cold foods and liquids
profuse urination or edema in cold climate or after ingesting cold liquids, eating raw or cold foods
craving for warm, cooked foods and hot drinks
pain in head, chest, limbs, joints aggravated by cold
pale, purplish skin, nail beds, lips, or tongue

Damp Heat

dryness or thirst without desire or ability to drink
feeling of heat in stomach or chest with a nauseating taste in the mouth
sticky yellow or green discharge from nose, throat, bronchi, urethra, or vagina
hot flashes with profuse perspiration
fever or heat not relieved by perspiring or drinking
loose or sticky stool streaked with mucus or pus
burning, red, oozing sores, boils, pimples, blisters or rashes
worse from heat and/or humidity, and sweet, spicy or oily foods

External Wind

itching or prickling sensations of skin, ears, eyes, nose; sneezing, headache
unpredictable or migrating pains
dizziness or headache with cold, flu, or allergy
muscle soreness or shivering in winds or drafts
numbness or pain of face or scalp
neck stiffness or spasm
worse from drafts, changing temperatures, pressure

Internal Wind

trembling hands, feet, head
disequilibrium, incoordination
contracture or quivering of tongue
spasms, twitches, cramps of nerves, muscles, viscera
vertigo, motion sickness, hypertension
headache with vertigo, numbness, spasms, parasthesia (strange sensations)
seizures, sequellae of stroke or T.I.A.
worse from wind, changing barometric pressure, or changing from lying to upright posture

Phlegm

dizziness or fullness in head from mucus congestion
nausea with phlegm in chest or throat
thick, sticky secretions from ears, eyes, nose, throat, mouth, anus, vagina or urethra
firm, mobile lumps, cysts, enlarged lymph nodes
worse in humid environment or from eating sticky, greasy, oily foods, milk products, eggs, sugar
sticky or greasy stool

Best Days/Time to contact you

This Health Profile is excerpted from Between Heaven and Earth: A Guide to Chinese Medicine (Beinfield & Korngold, Ballantine, 1991). This book is a good resource to help you understand more about Chinese medicine, available through local bookstores.