Interactive Questionnaires

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Five Element Theory Health Questionnaire

According to traditional Chinese philosophy, we are surrounded by five constantly moving and changing energy fields: earth, wood, fire, metal and water. Oriental Medicine uses this time-tested, diagnostic model to analyze how the various parts of a person's body and mind interact to affect health. Check the symptoms/illnesses you have recently experienced in the last 6 months. Often, people will have a predominance of symptoms in one of the elemental categories. This is an indication of an imbalance that should be addressed.

WATER WOOD FIRE EARTH METAL
Swollen Ankles
Anemia
Angina Pains
Clammy Hands
Bronchitis
Burning with Urination
Bitter Taste in Mouth
Anxiety
Lack of Appetite
Cough
Frequent Urination
Difficulty Digesting Oily or Fatty Foods
Frequent Crying
Low Blood Sugar
Chest Congestion
Frequent Urination at Night
Difficulty Making Plans or Decisions
Heat Intolerance
Belching or Burping
Shortness of Breath
Urine Retention
Easily Angered or Agitated
Nervousness
Sweet Cravings
Decreased Sense of Smell
Painful Urination
Eye Problems (tearing, itching, blurred vision)
Nightmares
Loose Stools or Undigested Food
Feeling of Claustrophobia
Kidney Stones
Gall Stones
Poor Memory
Afternoon Slump
Fever
Cold Intolerance
Hemorrhoids
Irregular Heart Rate
Nausea
Frequent Sore Throats
Decreased Sex Drive
Hepatitis
Pressure in Chest
Drowsiness
Asthma
Hair Loss
High Cholesterol
Easily Excitable
Tendency to be "Obsessive"
Nasal Problems
Knee Problems
Impatience
Mental Confusion
Fatigue after a Meal
Recent Use of Antibiotics
Night Sweats
Depression
Insomnia
Food Sensitivity
Frequent Colds
Fearful
Light-colored Stools
 
Easily Bruised
Chills
Ringing in Ears
Pain Under Ribs
 
Indigestion
Constipation
Burning Hands or Feet
Soft/Brittle Nails
 
Vomiting
Blood in Stool
Blood in Urine
Spasm or Twitching Muscles
 
Tendency to Worry
Inhalation of Toxic Chemicals
Low Blood Pressure
Stiff Neck/ Shoulders
 
Bloating
Swollen Lymph Glands
Salt Craving
Tightness in Ribs
   
Allergies
Stress
Varicose Veins
   
Infections
Sleeplessness
Anger
   
Chronic Illness
Dizziness
High Blood Pressure
   
Sweating Without Exercise
Dark Circles Under Eyes
Fever Blisters
   
Intolerant to Weather Changes
Low Back Pain
       
Hearing Impairment
       
Afternoon Fever
       

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San Diego, CA 92116
Phone: (619) 282-8068
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Phone: (619) 470-4714