Name *

First Name

Last Name

PATTERNS OF DEPLETION (Check the symptoms you have experienced during the last six months.)

DEFICIENT QI

weak, lethargic, weary

apathy

dull thinking or feeling

excessive need for sleep

susceptible to colds, flus, allergies

prolonged recovery following illness

pasty, pale complexion

shortness of breath

aversion to talking

perspires easily with exertion

easily chills

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

DEFICIENT MOISTURE

parched, thirsty

extreme dryness of skin or mucous membranes

scant secretions and urination

uncomfortable feeling of heat in the body

low afternoon fever with sweating

constipation

hot flashes

night sweats

unstable blood sugar, emotional lability

persistent dry cough

SLACK MOISTURE

excess secretions: eyes, nose, mouth, skin, vagina

seminal incontinence, premature ejaculation

frequent urination or incontinence

dizzy or weak after sex

DEFICIENT BLOOD

restless fatigue

emotional sensitivityOption 2

insomnia and anxious sleep

dryness without thirst

blurred or weak vision

thinning of hair

dry or hard stool

dry skin, eyes, hair, nails

anemia

muscle cramps

lack of semen

scanty or infrequent menstruation

insufficent lactation

pale, sallow complexion

poor skin healing

palpitations

night sweats

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

DIMINISHED ESSENCE

profound weakness

atrophy of muscles and organs

sagging or wrinkling of skin

diminished sexual arousal and pleasure

infertility or early menopause

repeated miscarriages

loosening or loss of teeth

early thinning or graying of head and pubic hair

decline of memory, vision or hear

progressive loss of weight or emaciation

compromised immunity

DISTURBED CHEN

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

PATTERNS OF CONGESTION

STAGNANT CHI

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 gasOption 2

wheezing and chest pain

difficulty swallowing, as if something stuck

stitch 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

OBSTRUCTED BLOOD

severe or constant headache

angina

traumatic bruises, swellings and sprains

stabbing or throbbing aches or pains

pain aggravated at night or from inactivity

severe cramping, numbness or paralysis

dark red or purple complexion

purple lesions on the skin, tongue, mouth or lips

severe menstrual cramps with dark blood or clots

hard or immobile lumps, masses or organs

ADVERSE CONDITIONS

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,abdomenor 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 postureworse 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

ORGAN NETWORK AND DISTUBANCES

LIVER NETWORK

dry eyes

blurred or unclear vision

easy chilling arms, hands, legs, feet

coarse, brittle nails or hair

touchiness from heat, wind, noise, bright light

numbness, tingling of limbs when asleep or inactive

muscle cramps of pelvis, sides, hips, calves, feet

tension in shoulders, neck, sacrum, hips, legs

stitching under diaphragm, between ribs, groin, pelvis

high pitched or loud ringing in the ears (tinnitus)

dizzy, queasy, flushed, headache from hunger, anger

hypersensitive genital organs

nervous, irritable, short tempered

HEART NETWORK

anxiety, dread

restless and excitable

mood swings (laughs easily, cries easily)

insomnia when nervous, worried or excited

restless sleep and vivid dreams or nightmares

cravings for cool drinks, juicy or hot, spicy foods

sores of mouth and tongue

easily overheats and perspires

easy blushing of face, chest, neck, and ears

burning, sensitivity or irritation of mouth, tongue, urethra, vagina or anus

frequent urination or bowel movements from nervousness

palpitations when nervous, upset or fatigued

easily confused or disoriented

SPLEEN NETWORK

tender muscles

slow digestion or indigestion

variable appetite

frequent abdominal gas or bloating

loose stool from raw or cold foods and liquids

lingering hunger after meals

hard to gain, lose or regulate weight

difficulty focusing, distractible

overwhelmed by details, upset by changes

lethargy and inertia

prolapse of stomach, intestines, uterus, vagina, bladder

lack of muscle tone or strength

water retention, puffiness, heaviness of head, limbs

easy bruising, prolonged or heavy menstruation

easily worried, obsessed

LUNG NETWORK

weakness of chest

respiratory allergies

runny nose or stuffy sinuses

frequent, lingering colds, coughs, throat clearing, laryngitis

morning attacks of coughing or sneezing

constant phlegm in chest or throat

shortness of breath, chest pain, wheezing from fatigue or exertion

dryness and tightness of mucous membranes or skin

urge to urinate after laughing, coughing, or sneezing

skin rashes, eczema, hives

sensitive to wind, cold and dryness

stiffness of joints and muscles

easily disappointed or offended

KIDNEY NETWORK

puffiness around eyes

diminished libido

loss or thinning of pubic hair

early cessation of menses, irregular cycle

disorder of urination

rigidity of spine and joints

difficulty conceiving or carrying to term

weak or sore low back, hips, knees, ankles or feet

lack of stamina and endurance

diminished motivation and apathy

forgetfulness and mental dullness

puffiness or swelling of feet and ankles

weak vision, dull hearing

low humming or buzzing in ears (tinnitus)

sore throat from fatigue or in the morning

easily defeated and disgruntled

CONFLICTS BETWEEN ORGAN NETWORKS

LIVER / SPLEN DISHARMONY

cold hands and feet with feeling of fullness in throat, chest, or abdomen

indigestion with nausea, bloating, flatulence, belching

erratic elimination, constipation or diarrhea

spasm, pain of esophagus, stomach, intestines, uterus

thirst for alternately cold and hot liquids

sensitivity or aversion to strong odors or flavors

erratic cravings for fatty, sour, or sweet foods

erratic appetite, difficulty knowing what to eat

tenderness, tension and heaviness in muscles, especially head, neck, jaw, elbows or knees

headache with heaviness or pressure behind eyes,nausea, diarrhea

sensitivity to light, noise, heat and humidity

variable blood sugar

eating disorders

irritable bowel

food sensitivity or intolerance

vacillates between assertiveness and ambivalence, irritability and lethargy

SPLEEN / KIDNEY DISHARMONY

slow digestion, sluggish intestines

weak gums and loose teeth

dryness and thirst with water retention

sore, swollen joints and muscles

heaviness, weakness and soreness of head, neck, back, sacrum and limbs

loose or dry, small stool with bloating

frequent, scanty or difficult urination

easily chilled in back, belly, legs or arms

craves salty or sweet foods, causing constipation, dryness and water retention

edema

rheumatism

cystitis, urethritis, vaginitis, leucorrhea

prostatic hypertrophy or prostatitis

distractible, insecure, volatile or apathetic, inert

KIDNEY / HEART DISHARMONY

insomnia or restless sleep alternating with heavy slumber and difficulty awakening

nervousness or mood swings alternating with fatigue and lumbar weakness

easily overheated or chilled

hot chest, head, ears, face and hands, with cold belly, buttocks, feet

easily enthused but difficult to sustain effort or excitement

melancholy and restless after prolonged mental or physical exertion

sexually excitable but difficult to sustain arousal or achieve release

anxiety, despair, phobias

nausea, diarrhea, urinary frequency associated with anxiety or fright

craves salty, spicy food and stimulants

chronic endometritis/cervicitis/urethritis

HEART / LUNG DISHARMONY

sensitivity to changes in temperature and humidity

easily overheated but can’t sweat

dry cough with heat in throat or chest

flushes when coughing, laughing, or sneezing

heat triggers sneezing, itchy throat or rashes

dry skin with cracking, redness and itching, especially from cold and dryness

light sleeper and wakes easily

itching, inflammation of vagina or urethra without discharge

alternately euphoric and melancholic, hysterical or depressed

easily hurt or offended

craves spicy, hot foods and stimulants

hives, eczema, rashes, worse in daytime

LUNG / LIVER DISHARMONY

tense, stiff neck, shoulders, chest, or loins

irregular bowel movements

sensitivity or aversion to strong odors or flavors

loss of ability to smell

irregular, tense or shallow breathing wheezing or sighing

sensitive, easily irritated skin or mucous membranes of upper respiratory or genito-urinary tracts

sensitivity or aversion to heat, dryness, wind, drafts or sudden changes in weather

feels awkward expressing feelings or reactions

craving for fatty, sour and spicy foods

hives, itching, worse at night

sensitive to rage or rejection

seasonal sinusitis or hay-fever

bursitis, lumbago or sciatica that comes and goes

neck spasms, and occipital or lateral headaches

depressed, sad, quiet, angry

ARCHETYPAL SELF ASSESSMENT PROFILE

WOOD ARCHETYPE: The Pioneer

feel confident, act assertively

ambitious & enjoy competition

enjoy being first, best, unique

can be pushy or provocative

openly discuss abilities and achievements

comfort with challenges, conflict, pressure

right, even if others disagree or disapprove

pleasure in public recognition

comfortable directing or leading others

follow my own hunches, take initiative

comfortable with bold, decisive action

tend to argue with opinions, especially of me

FIRE ARCHETYPE: The Wizard

enjoy the pleasure of my senses

seek excitement & stimulation

intuitive about what others think or feel

seek physical contact, emotional intimacy

easily share innermost feelings & desires

tend to live in the here-and-now

see the humorous side of life

get involved easily, moved emotionally

optimistic & hopeful no matter what

identify with another’s joy & pain

unabashed affection, enthusiasm & excitement

enjoy being attractive & magnetic

EARTH ARCHETYPE: The Peacemaker

agreeable and accommodating

nurturing, putting other’s needs first

seek socializing with friends and family

seek being relied upon for reassurance & help

the hub of my social and family networks

mediate disputes so that all are satisfied

involved in other peoples’ lives

create comfortable environment for others

loyal & accessible

diplomatic and tactful—a consensus builder

happy to rely on skills & intelligence of others

like getting close & being needed

comfortable & open, even with strangers

METAL ARCHETYPE: The Alchemist

prefer a neat & orderly lifestyle

enjoy convivial but undemanding social life

committed to moral principles & conduct

enjoy logical, systematic problem-solving

meticulous, tasteful, discriminating

self-contained

temperate & moderate

enjoy solving puzzles and mysteries

appreciate well defined goals and guidelines

accept authority of those with more competence

virtue & principle before pleasure & fulfillment

likes things to run calmly & smoothly

WATER ARCHETYPE: The Philosopher

cautious, sensible, self-sufficient

enjoy solitude, cherish privacy

curious & imaginative

content being anonymous

keep feelings, thoughts, opinions to myself

don't mind being unusual or eccentric

excited by intellectual pursuits

careful about what I reveal to others

stubborn defender of the truth as I see it

patient & persevering in spite of defeats

objective & fair, regardless of others

content figuring things out for myself