|
| Eye-related | Never | Seldom | Sometimes | Often | Almost always |
|
| Sensitivity to light (or to bright lights) | □ | □ | □ | □ | □ |
| Dry eyes | □ | □ | □ | □ | □ |
| Teary eyes | □ | □ | □ | □ | □ |
| Blurred vision | □ | □ | □ | □ | □ |
| Sore eyes | □ | □ | □ | □ | □ |
| Red eyes | □ | □ | □ | □ | □ |
| Swollen eyelids | □ | □ | □ | □ | □ |
| Eye twitching | □ | □ | □ | □ | □ |
| Floaters in the eyes | □ | □ | □ | □ | □ |
| Burning sensation in the eyes | □ | □ | □ | □ | □ |
| Itchy sensation in the eyes | □ | □ | □ | □ | □ |
|
| Face related (mouth, ear, and nose) |
| Sensitivity to sound (or to loud noises) | □ | □ | □ | □ | □ |
| Dry mouth | □ | □ | □ | □ | □ |
| Thirst | □ | □ | □ | □ | □ |
| Bitter taste in the mouth | □ | □ | □ | □ | □ |
| Runny nose | □ | □ | □ | □ | □ |
| Sore throat/feeling of foreign body in the throat | □ | □ | □ | □ | □ |
| Ear discharge | □ | □ | □ | □ | □ |
| Tinnitus (ringing in the ears) | □ | □ | □ | □ | □ |
| Flushed face/hot red face | □ | □ | □ | □ | □ |
|
| Digestion-related |
| Nausea | □ | □ | □ | □ | □ |
| Vomiting | □ | □ | □ | □ | □ |
| Reflux | □ | □ | □ | □ | □ |
| Belching | □ | □ | □ | □ | □ |
| Bloating/flatulence | □ | □ | □ | □ | □ |
| Indigestion | □ | □ | □ | □ | □ |
| Poor appetite/loss of appetite | □ | □ | □ | □ | □ |
|
| Urine and bowel related |
| Yellowish urine | □ | □ | □ | □ | □ |
| Frequent urination (especially at night) | □ | □ | □ | □ | □ |
| Watery bowel motion | □ | □ | □ | □ | □ |
| Loose bowel motion | □ | □ | □ | □ | □ |
| Dry stools | □ | □ | □ | □ | □ |
| Constipation | □ | □ | □ | □ | □ |
|
| Muscle- and joint-related |
| Joint stiffness | □ | □ | □ | □ | □ |
| Neck stiffness | □ | □ | □ | □ | □ |
| Muscle twitching | □ | □ | □ | □ | □ |
| Weak legs and knees | □ | □ | □ | □ | □ |
| Feeling weak in the lower back | □ | □ | □ | □ | □ |
| Feeling cold in the lower back or lower back pain worsened by coldness | □ | □ | □ | □ | □ |
| Cold hands and feet/cold limbs | □ | □ | □ | □ | □ |
| Hot sensation in the palms | □ | □ | □ | □ | □ |
| “Pins and needles” or numbness in the hands and/or feet | □ | □ | □ | □ | □ |
|
| Other symptoms |
| Increased forgetfulness or poor memory | □ | □ | □ | □ | □ |
| Feeling depressed | □ | □ | □ | □ | □ |
| Irritability/irascibility (short-tempered, easily angered) | □ | □ | □ | □ | □ |
| Restlessness | □ | □ | □ | □ | □ |
| Fatigue/tiredness | □ | □ | □ | □ | □ |
| Faintness | □ | □ | □ | □ | □ |
| Heavy sensation in the body | □ | □ | □ | □ | □ |
| Insomnia (difficulty falling asleep or staying asleep) | □ | □ | □ | □ | □ |
| Sighing often | □ | □ | □ | □ | □ |
| Feverish sensation | □ | □ | □ | □ | □ |
| Shortness of breath | □ | □ | □ | □ | □ |
| Dizziness | □ | □ | □ | □ | □ |
| Excessive phlegm | □ | □ | □ | □ | □ |
| Palpitation (feeling the heart beats quickly or unusually) | □ | □ | □ | □ | □ |
| Inability to concentrate | □ | □ | □ | □ | □ |
| Night sweating | □ | □ | □ | □ | □ |
| Sweating upon mild activity | □ | □ | □ | □ | □ |
| Aversion to cold or fear of being cold | □ | □ | □ | □ | □ |
| Aversion to hot or fear of being hot | □ | □ | □ | □ | □ |
| Sensitive to temperature changes | □ | □ | □ | □ | □ |
| Others (please specify) |
|
