Traditional Chinese Herbal  Diagnosis 

 for WOMEN

We don't promise a cure just 100% complete satisfaction

name      

height

weight

Blood pressure

describe your pulse 

(heart rate) 

age    

  don't know more than 60 beats per minute less than 50 beats per minute 50-60 beats per mminute

occupation 

          I try to exercise daily exercise weekly seldom if ever

Strong

robust 

5

4

intermediate

2

weak

frail

1

Would you describe your present physical-emotional state as

strong and robust 

beginning to be worn down

adversely affects 

Physically weary

Physically exhausted

My emotional well-being

not affected 

beginning to affect 

adversely 

affects

emotional

exhausted

   physically and emotionally no problem just need a little bit of help

   somewhere in between

   physically and emotionally I need a break and I need it NOW

   Chronic, enduring disease, I can live with it  BUT I would prefer not

do you frequently or recently have 

used enema or  bowel cleansing Colonic / Colon Cleanse 

took a steam bath or sauna

exercised or worked-out vigorously producing a sweat 

shower or bathed  and gone outside immediately after

Yin and Yang Energy of the Body

Feeling hot at room temperature 

Feeling cold desire for warm clothes

Desire for cold drinks or cold showers

Desire for hot drinks or hot baths

Red face

Pale face

Body temperature over 98.60 F (37C)

Body temperature under 98.60  F (37C)

Red tip of the tongue

Coldness of the back or neck

Burning diarrhea

Diarrhea without burning sensation

Burning urination strong steam

Weak stream during urination

Pungent fecal odor

Faint fecal odor

Fast pulse

hearing or speaking difficulties

Skipped heart beats

Cold hands and  feet

Hands and feet hot or sweaty

Cold feet (only)

Lips chapped

affected area can not be touched

Subjective sensation or feeling of heat or chills or actually fever and shivering

feeling of heat throughout the body

Chills Sensation of Cold

Heat in the joints and skin

Abdominal pain

Burning urination

frequent urination

Spasmodic Pain

tension in shoulders and neck 

Burning Pain

Muscle Spasms 

hot flashes

stiff muscles

Heartburn

Oozing Wounds

Bad breath

runny nose

sticky sweat

asthma with expectoration of phlegm

Tenesmus, ineffectual urge to defecate or urinate 

Watery Diarrhea 

Deficiency of the Body's Energy (Qi Xu)

  Easy fatigue after exercise

  General fatigue sensitivity to cold

  Daytime sleepiness

  Swelling water retention 

  Frequent infection

  Slow pulse without athletic training

  Jelly / beer belly 

or reduced tension in lower abdomen

  Flabby’ muscles, lack of strength

sweaty palms or feet

  Feeble voice

  Loss of appetite

  Frequent diarrhea  

  Easily frightened

  Collapsed organs (weak bladder hemorrhoids hernia prolapsed uterus)

  Lack of willpower

Stagnation of the Body's Energy (Qi Stasis)

  Depression

  Lump in the throat

  Difficult getting out of bed in the morning

  Chest Cold, Stuffy, Asthmatic

  Heavy feeling in the head as if wearing hat

  Pain or distention sides of the chest

  Bloating, gas

  Pain that drifts through the body

  Stomach rumbling

  frequent flatulence or gas

  Feeling of incomplete urination

  Hiccups

Qi Rebellion  

  Abdominal palpitations

  Red Face

  Coughing attacks irritability

  Impatience

  Racing heart for no apparent reason

  Recurrent headaches

  Vomiting

  Easily frightened

  Painful spasms in the abdomen

  Sweaty hands and feet

  Cold hands and feet

   Milk Intolerance

Gluten intolerance

  Upper part of the body Hot 

      while Lower part  Cold 

Fluids Affecting the Body

 Edema of the whole body 

  Edema of hands, body and face only

  Edema of the abdomen only

  Edema of the legs and ankles only

  Glands,  Swollen, painful

Fluid

  Any Edema

  Congestive heart failure

  Excessive urination

  Stiff joints in the morning

  Dizziness

  Passing out / Dizzy when getting up

  Motion sickness

  Watery diarrhea

  Palpitations above umbilicus

  Frequent urination

  Throbbing headache

  Foamy saliva

  Nausea, vomiting

  Feeling of heaviness

  Runny nose

  Drooling

  Sore or painful Low back

Painful joints and muscles which may be swollen but are not red or hot to the touch. The pain feels better with  warmth and touch

Condition of the Blood 

 Dry or  rough skin

Loss of tactile sensation in the skin

Pale complexion

Red gums

Eyesight Decreased visual acuity at night

Red tongue

Insomnia

Red lips

Symptoms worse at night

Hemorrhoids

Hair loss

Tenderness left side of the navel

Broken, brittle or dry  nails

Tenderness right side of the navel

Dizziness

Tenderness below the rib cage

Muscular weakness

Tenderness lower abdomen

Lumps Fixed, that are painful

Spider’ veins , varicosities, moles

Facial freckles

Scanty or missed menstrual periods

Dark circles under the eyes

Menstruate Blood clots

Rash on the palms

Muscle cramps

I am not on the pill

I am pregnant

women who stop using the pill after some years very often develop amenorrhea (lack of menstruation) or a very irregular-late cycle. This condition usually resolves within a few months of  herbal therapy 

The Contraceptive Pill regularizes the periods and makes them scanty. An IUD makes the periods heavier or more painful. If you are on either please refer to your cycle prior before use.

Menstrual Cycle

TCM considers 28 days normal, however I consider the regularity and consistency of the cycle to be more important

NOTE:  Hold Down Ctrl while clicking with the mouse to select more than one response.

Regular menstruation EARLY usually more than 7 days LATE, usually more than 7 days IRREGULAR, sometimes early sometimes late Irregular or painful Irregular, painful or difficult Irregular, painful or intermittent Irregular intermittent Scanty Absent fluctuates between being early and late Painful or delayed with large clots, dark or scanty flow

Amount 

normal, between 30 and 80 ml heavy, either profuse or prolonged scanty or light bleeding

Color

During normal menstrual the blood varies from dark-red  lighter in the beginning, deep red in the middle and pinkish at the end.

Normal Dark Red or Bright Red Pale Blackish, very dark Purplish Brownish and dilute Scarlet Red  

Consistency

Normal flow is smooth without clots, neither thin or thick

Normal Clotted with dark dull clots Clotted with Dark but fresh looking clots Clotts Large Clotts Small Dark, bout blood not dark Watery  

Menstruation are OK Blood clots Painful or delayed with large clots, dark or scanty flow Fatigue Weakness during or following  Bloating with a feeling of heaviness or water retention Lengthy build-up, retarded flow, or prolonged bleeding Tension, irritability, with pressure or fullness in the head, breasts,  abdomen Cravings for sweet. Sluggish painful abdomen constipation  diarrhea. frequent urinre Hot flashes,  perspiration, painful intercourse, inflammation or irritations hunger EARLY usually more than 7 days

No menopausal issues Pre-menopasual symptoms sometimes Post menopause Premature or difficult  menopause Premature following surgery, chemotherapy, childbirth, or illness Menopause or age-related osteoporosis, history of stress fractures, or bone fragility

No Miscarriages or Pregnancies Habitual Miscarriage Recurrent Miscarriage  or premature labor Threatened  Miscarriage Labor Prolonged ineffectual

Bowel Movements (Constipation / Diarrhea, loose stools)

Normal and regular once a day well formed slight odor Normal  like clockwork Fatigue or dizziness after movement Cramping and flatulence with irregular movements Stool Dry  Hard Stool Dark Bad Odor Constipation Constipation with Dry Stool Constipation with Distension and Gas in lower abdomen Constipation or Diarrhea with fever flushing burning anus Incontinence Fecal Stool Loose Stool Loose Irregular Stool Loose with decreased urination Stool Loose Frequent or continuous Loose after eating raw or cold foods Stool Loose with burning or sticky mucus, or blood-streaked, smelly discharge

Urination (click all that apply)

normal slight yellow no odor few  times a day Urination Absent, scanty, restricted, or painful Urination Burning, dark, scanty, or turbid Urination Difficult or Painful Fatigue or dizziness after urinating or following sex Frequent or excessive Frequent or urgent with decreased output Incontinence urinary Enuresis Incontinence when laughing or coughing Profuse in cold environment or after drinking cold liquids Urination retention Scanty or concentrated Scanty, dark yellow, burning Urinary discomfort associated with nervousness

Please  select all that apply

Hold Down Ctrl while clicking with the mouse to select more than one response.

Breast Distention Breast Lumps see also specific dx for breasts lumps Cramps Cystitis Cysts ovarian, uterine fibroids Edema during PG Endometriosis Fetus restless Hemorrhoids, especially after childbirth Induced labor Infertility inflammation pelvic region Mastitis Menopause Menorrhagia Menses Amenorrhea Menses Clots Menses containing pus Menses continuous dark Menses continuous light flow Menses difficult Menses early w/pale blood Menses heavy periods Menses irregular Menses Painful Dysmenorrhea Menses scanty periods Menses short red purple Menses swelling EDEMA Miscarriage Morning sickness Placenta retained PMS Post Partum Recovery Prolapse of the uterus, rectum, or stomach Sexual dysfunction Skin outbreaks beginning with menstrual period Uterine bleeding Uterine fibroids Uveitis Vagina, white discharge Vaginal infections

Please describe your TONGUE 

color          normal Pale White Red Yellow Blue or Purple

condition     Normal Dry Wet Swollen with teeth marks on the edges

          My  body type may be described as Tall and Slender Strongly built Square Body heavy large frame round body triangle shape, small hands and feet

Medical History.  Select the most applicable to your present condition 

Hold Down Ctrl while clicking with the mouse to select more than one response.

Abdominal Distress Acne ADD/ADHD Addiction recovery (including sugar, caffeine) Adrenal insufficiency Age spots Allergic colitis Allergic reactions of the skin allergic reactions type I + IV Allergies Alzheimer-dimentia Amebiasis Anemia Angina Angioedema Anhidrotic Anxiety Aphasia Appendicitis appetite craves not satisfied. Sweet tooth Appetite increased Appetite loss Apraxia Arthralgia Arthralgia w/ numbness Arthritis Ascetics ascites from liver failure Asthma atherosclerosis, Athlete's foot Autoimmune Disorders Back low sore + weak nor acute Back pain especially in the coccyx. or tail bone. Bad breath Bells Palsy Billary Ascariasis  Intestinal Parasites Bipolar Disorder Bleeding / bloody stool Bleeding induced by alcohol or aspirin. Body ache or muscle pain, in the neck and shoulders Body Aches Boils Bronchial Difficultés Breathing Difficulties Bursitis Candias_ infection Cancer Liver Canker Sores Carbuncles Cardiac Asthma Cardiac Failure Cardiac Insufficiency Cellulites Cerebral  Arteriosclerosis Cerebral palsy Cerebrovascular Cervical Erosion Cervical myositis acute Cervictis Chemotherapy Support Chest / Epigastrium Distress Chills chills and fever chills alternating with fever Cholecystitis Cholesterol high Chronic_ Cough Circulation Poor venous Circulation poor to the brain Cirrhosis Colic Conjunctivitis Colitis Congestive Heart Failure Cor Pulmonale Corneal Ulcers Coronary Artery Disease Costohondritis Constipation chronic long term Crohn's disease Cystitis Cysts ovarian, uterine fibroids Deafness, sudden Depression Dermatitis Dermatitis contact: type IV allergic reactions Diabetes Diabetes insulin-dependent Diabetes type 1and type 2 Diabetes with long-term gastrointestinal disorders Dystonia of intestinal tract Edema during PG Emphysema Endometriosis Enteritis Epilepsy Flatulence Frozen shoulder Furuncle Gallstones Gastritis- gastroenteritis Gentiacals Testicles, swollen Gingivitis Glaucoma Glomerulonephritis Glomerulonephritis Goiter Gonorrhea Gout Grave's disease Gum disease acute symptoms Hay fever Headache Headache Migraine Headache Neurogenic Hearing, loss Heart disease Heartburn Hemiplegia Hemorrhage fever Hemorrhoids Hepatitis Herpes Hiccough High Blood Pressure High cholesterol Hirsutism (excessive body hair) Hives Hoarseness Hydrocele (Swollen testicles) Hyperaldosteronism Hypertension Hyperthyroidism Hypopituitarism Hysteria H.pylori infection Impotence Incontinence Indigestion infertility Insomnia Intestinal flu, obstruction, adhesions Irritability Irritable bladder syndrome irritable bowel syndrome Ischemic Attacks Jaundice Laryngitis Leiomyoma Leptospirosis Lesions Leucorrhoea Lochioschesis lung abscess Lupus Lymph glands swollen Macula Mastitis Measles Meniere's Disease Meningitis Multiple Sclerosis Myalgia Myasthenia Gravis Mycoplasma Nephritis Neuralgia Neuralgia intercostals Neuralgia trigeminal Neurasthenia Neurogenic bladder Nocturnal emissions Nodules Nosebleed Recurrent Numbness Obesity Obsessive Behavior Ochitis Optic nerve atrophy Dizziness moving from seated to standing Osteoarthritis Osteoporosis after menopause Otitis media Palpitation Pancreatitis Paralysis Parasites roundworms Parotitis Pelvic or peritoneal adhesions Periodontitis Petechiae PID Pelvic inflammatory disease Pigmentosa Pleuritis Pneumonia Pneumonia, mycoplasmic Polio Prolapse of the uterus, rectum, or stomach Prostatitis Psoriasis Pulmonary Purpura Pyelitis Pyelonephritis Pyloric obstruction Renal colic Renal failure Respiratory distress Retinitis  Rheumatic fever heart disease valvular heart Rheumatoid arthritis, chronic Rhinitis allergic Roundworms bile duct Salpingitis Schistosomiasis Seizures Septicemia Sexual dysfunction in both men and women Shingles Sjbgren's syndrome. Sjogren's syndrome. Spermatorrhea Stomatitis (mouth sores) Stones Bladder Stones Kidney Supraventricular arrhythmia Supraventricular tachycardia Syncope (food retention) Tachycardia TB TB colon Intestinal Tendentious Thrombocytopenic Tinea Tingling Tremor Twitching sensations Tinnitus Tonsillitis Ulcer Ulcer Gastric Ulcer Peptic Upper Respiratory Tract Infection Urethritis Urinary calculi (stones) Urinary Tract Infection Urination nocturnal Urination Painful (Dysuria) or difficult Recovery after prostate surgery helping to re-establish normal urination Urination scanty or incomplete Urine turbid Urolithiasis Urticaria Uterine bleeding Uveitis Vagina, white discharge Vaginal infections Varicocele Varicose veins Vertigo Viral infections vitiligo

additional comments

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We will return your diagnosis via email with a herbal recommendation.  In many cases this may help you to make an informed choice regarding your health and may prove useful in deliberations with your local health care practitioner. In some cases it may be necessary to have a office visit where a more complete diagnosis and treatment can be made. Completing this form we believe will help the process along quickly and efficiency.  Please remember this is not a western diagnosis of a medical disease. It is a Traditional Chinese Medicinal approach treating disorders of the Yin and Yang, Qi, Blood and Fluids with herbs and where necessary in the office with acupuncture.