stcacupuncture.com - Infertility Questionnaire

Answer yes or no to each question. Do not think too much about each question, just answer whether or not you have experienced it. We will correlate your answers with the results of Acupuncture Meridian Imaging test.

KIDNEY YIN DEFICIENCY (Ki Yi-)

Rows	Yes	No
Do you have lower back weakness, soreness, or pain, or knee problems?
Do you have ringing in your ears or dizziness?
Is your hair prematurely gray?
Do you have vaginal dryness?
Is your midcycle fertile cervical mucus scanty or missing?
Do you have dark circles around or under your eyes?
Do you have night sweats?
Are you prone to hot flashes?
Would you describe yourself as afraid a lot?
Does your tongue lack coating? Does it appear shiny or peeled?

KIDNEY YANG DEFICIENCY (Ki Yan-)

Rows	Yes	No
Do you have lower back pain premenstrually?
Is your low back sore or weak?
Are your feet cold, especially at night?
Are you typically colder than those around you?
Is your libido low?
Are you often fearful?
Do you wake up at night or early in the morning because you have to urinate?
Do you urinate frequently, and is the urine diluted and / or profuse?
Do you have early morning loose, urgent stools?
Do you have profuse vaginal discharge?
Does your menstrual blood tend to be dull in color?
Do you feel cold cramps during your period that respond to a heating pad?
Is your tongue pale, moist and swollen?

SPLEEN QI DEFICIENCY (Sp-)

Rows	Yes	No
Are you often fatigued?
Do you have poor appetite?
Is your energy lower after a meal?
Do you feel bloated after eating?
Do you crave sweets?
Do you have loose stools, abdominal pain, or digestive problems?
Are your hands and feet cold?
Is your nose cold?
Are you prone to feeling heavy or sluggish?
Are you prone to feeling heaviness or grogginess in the head?
Do you bruise easily?
Do you think you have poor circulation?
Do you have varicose veins?
Are you lacking strength in your arms and legs?
Are you lacking in exercise?
Are you prone to worry?
Have you been diagnosed with low blood pressure?
Do you sweat a lot without exerting yourself?
Do you feel dizzy or light-headed, or have visual changes when you stand up fast?
Is your menstruation thin, watery, profuse or pinkish in color?
Are you more tired around ovulation or menstruation?
Do you ever spot a few days or more before your period comes?
Have you ever been diagnosed with uterine prolapse?
Are your menstrual cramps accompanied by a bearing-down sensation in your uterus?
Are you often sick, or do you have allergies?
Have you been diagnosed with hypothyroid or anemia?
Do you have hemorrhoids or polyps?
Does your tongue look swollen, with teeth marks on the sides?
Do you have a pale, yellowish complexion?

BLOOD DEFICIENCY (Bl-) (not necessarily equated with anemia)

Rows	Yes	No
Are your menses scanty and /or late?
Do you have dry, flaky skin?
Are you prone to getting chapped lips?
Are your fingernails or toenails brittle?
Are you losing hair on your head ( not in patches, but all over)?
Is your hair brittle or dry?
Do you have diminished nighttime vision?
Do you get dizzy or light-headed around your period?
Are your lips, the inner side of your lower eyelids, or tongue pale in color?

BLOOD STASIS (Bl X) (often associated with blood deficiency symptoms; see Bl-)

Rows	Yes	No
Is your menstrual flow ever brown or black in color?
Do you feel midcycle pain around your ovaries?
Do you have painful, unmovable breast lumps?
Do you experience periodic numbness of your hands and feet (especially at night)?
Do you have varicose or spider veins?
Do you have red hemangiomas (cherry-red spots) on your skin?
Does your complexion appear dark and “sooty”?
Do you have chronic hemorrhoids?
Does your menstrual blood contain clots?
Have you been diagnosed with endometriosis or uterine fibroids?
Is your lower abdomen tender to palpation (resisting touch)?
Can you feel any abnormal lumps in your lower abdomen?
Do you have piercing or stabbing menstrual cramps?
Does your tongue look dark?
Do you have dark spots on your tongue?
Are the veins beneath your tongue twisty and tortuous?
Do you have dark spots in your eyes?
Have you been diagnosed with any vascular abnormality or blood clotting disorder?

LIVER QI STAGNATION (Lv Qi X)

Rows	Yes	No
Are you prone to emotional depression?
Are you prone to anger and / or rage?
Do you become irritable premenstrually?
Do you feel bloated or irritable around ovulation?
Does it feel as if your ovulation lasts longer than it should?
Are your breasts sensitive/ sore at ovulation?
Do you experience nipple pain or discharge from your nipples?
Do you have a lot of premenstrual breast distention or pain?
Have you been diagnosed with elevated prolactin levels?
Do you become bloated premenstrually?
Are your pupils usually dilated and large?
Do you have difficulty falling asleep at night?
Do you experience heartburn or wake up with a bitter taste in your mouth?
Are your menses painful?
Do you feel your menstrual cramps in the external genital area?
Is the menstrual blood thick and dark, or purplish in color?
Is your tongue dark or purplish in color?

HEART DEFICIENCY (Ht-) (often associated with heat)

Rows	Yes	No
Do you wake up early in the morning and have trouble getting back to sleep?
Do you have heart palpitations, especially when anxious?
Do you have nightmares?
Do you seem low in spirit or lacking in vitality?
Are you prone to agitation or extreme restlessness?
Do you fidget?
Is the tip of your tongue red?
Is there a crack in the center of your tongue that extends to the tip?
Do you sweat excessively, especially on your chest?

EXCESS HEAT (^H)

Rows	Yes	No
Is your pulse rate rapid?
Are your mouth and throat usually dry?
Are you thirsty for cold drinks most of the time?
Do you often feel warmer than those around you?
Do you wake up sweating or have hot flashes?
Do you break out with red acne (especially premenstrually)?
Do you have a short menstrual cycle?
Do you have vaginal irritation or rashes?

DAMPNESS (D)

Rows	Yes	No
Do you feel tired and sluggish after a meal?
Do you have fibrocystic breasts?
Do you have cystic or pustular acne?
Do you have urgent, bright, or foul-smelling stools?
Does your menstrual blood contain stringy tissue or mucus?
Are you prone to yeast infections and vaginal itching?
Do your joints ache, especially with movement?
Are you overweight?
Do you have a wet, slimy tongue?

DAMP HEAT (DH)

Rows	Yes	No
Do you have signs of heat and /or dampness as indicated above?
Do you have foul-smelling, yellow, or greenish vaginal discharge?
Are you prone to vaginal and/ or rectal itching during your lutealor premenstrual phase?

COLD UTERUS (CW)

Rows	Yes	No
Do you fit the Kidney Yang deficiency (Ki Yan-) category?
Do you fall into the Blood stasis pattern?
Does your lower abdomen feel cooler to the touch than the rest of your trunk?

Acupuncture Patterns

DIAGNOSIS