PATIENT MEDICAL SYMPTOMS
Please check all symptoms that pertain to you at the current time.
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Cold hands/feet
Bad breath
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Fatigue
Large appetite
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Feverish in the afternoon or flushes
Mouth, canker or cold sores
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Heat sensation in hands, feet, chest
Bleeding, swollen or painful gums
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Night sweats
Heartburn/belching
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Catch colds easily
Stomach pain
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Sweats easily during daytime
Vomiting/nausea
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Dizziness
Diarrhea alternating with constipation
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See floating black spots
Tight/suffocating feeling in chest
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Bitter taste in mouth
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Palpitations
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Blood shoot eyes/dry eyes
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Sore on tongue
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Anger easily
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Restlessness
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Skin rashes
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Anxiety
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Headache
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Chest pain
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Numbness of hands and feet
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Insomnia
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Muscle spasms, twitching, cramping
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Cough
Seizures/convulsions
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Sinus congestion
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Sore, cold or weak knees
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Dry mouth, throat, nose, or skin
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Low back pain
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Allergies seasonal or food
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Frequent urination
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Chills and fever
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Get up more than once a night to urinate
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Stiff neck/shoulders
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Lack of bladder control
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Sore throat
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Memory problems
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Difficult breathing
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Hair loss
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Ringing in ears
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Low appetite
Urine is:
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Loose stools
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Normal color
Clear
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Constipation
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Dark yellow
Reddish
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Abdominal bloating or gas after eating
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Cloudy
Scanty
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Feeling tired after eating
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Bad odor
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Prolapsed organs (previously diagnosed)
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Burning
Painful
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Bruises easily
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Difficult
Urgent
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General feeling of heaviness in body
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Mental heaviness or fogginess
Libido (sex drive) is:
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Swollen hands/feet
Normal
Low
High
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Burning sensation after eating