In-Depth Health Evaluation from the Perspective of Traditional Chinese Medicine (TCM) at ActiveHerb

Healing Light Holistic Center

Quick Hormonal Evaluation

For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

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Hot Flashes: yes Night Sweats: yes Vaginal Dryness: yes Foggy Thinking: yes Memory Lapses: yes Incontinence: yes Tearful: yes Depressed: yes Sleep Disturbance: yes	Pale face: yes no. Flushed face: yes no. Fatigue: yes no. Lassitude: yes no. Weak voice: yes no. Lack of interest in talking: yes no.

Short of breath: yes no.
Weak pulse: yes no.

Headaches: yes no.
Migraine headaches (one side): yes no.
Tension headaches: yes no.
Cluster headaches: yes no.
Dizziness: yes no.
Spinning: yes no.
Tinnitus (ring in the ears): yes no.
Blurred vision: yes no.
Red eye: yes no.
Eye pain: yes no.
Hair loss: yes no.
Hair graying: yes no.

Sore throat: yes no.
Difficult chewing or swallowing: yes no.
Dry mouth: yes no.
Thirst with desire for drinking: yes no.
Thirst without desire for drinking: yes no.
Bitter mouth: yes no.
Mouth odor: yes no.
Noticed difference in tongue color and coating from others: yes no.

Running Nose: yes no.
Stuffy Nose: yes no.
Cough: yes no.
Cough with little phlegm: yes no.
Cough with water phlegm: yes no.
Cough with yellow phlegm: yes no.
Cough with bloody phlegm: yes no.
Dry cough: yes no.
Wheezing: yes no.
Asthma: yes no.

Chest pain: yes no.
Abdominal pain: yes no.
Abdominal pain, relief with pressure: yes no.
Abdominal pain, worse with pressure: yes no.
Flank pain: yes no.
Shoulder pain: yes no.
Low back pain: yes no.
Low back weakness: yes no.
Arm pain: yes no.
Leg pain: yes no.
Arm/leg weakness: yes no.
Extremity numbness: yes no.
Leg pain while walking: yes no.
Joint pain: yes no.
Joint swelling: yes no.

Forgetfulness: yes no.
Emotional stress: yes no.
Mood swings: yes no.
Restlessness: yes no.
Depression: yes no.
Anxiety: yes no.
Irritability: yes no.
Mania: yes no.
Sleepiness: yes no.
Difficulty falling asleep: yes no.
Difficulty staying asleep: yes no.
Frequent awakenings: yes no.
Insomnia: yes no.
Dreamfulness: yes no.
Palpitation: yes no.
Angina: yes no.

Recent weight gain: yes no.
Recent weight loss: yes no.
Edema: yes no.
Poor appetite: yes no.
Nausea: yes no.
Vomiting: yes no.
Bloating: yes no.
Abdominal distention: yes no.
Indigestion: yes no.
Heartburn: yes no.
Stomachache: yes no.
Change in bowl habits: yes no.
Dry stool: yes no.
Loose stool: yes no.
Bloody stool: yes no.
Diarrhea: yes no.
Constipation: yes no.
Anal burning: yes no.

Frequent urination: yes no.
Urinary urgency: yes no.
Urinary pain: yes no.
Urinary dripping: yes no.
Urinary difficulty: yes no.

Women only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Pain in menstruation: yes no.
Menstruation disorders: yes no.
Menstruation irregularity: yes no.
Bleeding between periods: yes no.
Bleeding after menopause: yes no.
Hot flash: yes no.
Breast distention: yes no.
In pregnancy: yes no.
In lactation: yes no.

Men only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Premature ejaculation: yes no.
Weak erection: yes no.
Impotence: yes no.
Excessive sexual drive: yes no.
Loss of sexual drive: yes no.
Emission: yes no.
Active sexual life: yes no. How often:
Masturbation: yes no. How often:

Do you have other comments on your health?

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