Fatigue | □ 0: None □ 2: Cannot sustain heavy work □ 4: Can manage mild intensity work □ 6: Can only do daily activities |
Weakness and soreness of the low back and knees | □ 0: None □ 2: Occasional □ 4: Need to alter body position for relief □ 6: Persistent pain, need to take pain medication |
Heat sensation in the palms and soles | □ 0: None □ 2: Occasional □ 4: Desire to expose extremities □ 6: Desire to hold something cold |
Dry mouth and throat | □ 0: None □ 2: Mild □ 4: Decreased saliva production □ 6: Severe thirst with constant need to drink fluids |
Qi deficiency and listlessness | □ 0: None □ 2: Shortness of breath after mild activity □ 4: Shortness of breath after moderate activity □ 6: Unable to talk or catch breath even without activity |
Catch cold easily | □ 0: No colds □ 1: At least 6 times per year □ 2: At least 10 times per year □ 3: 12 or more times per year |
Pale complexion | □ 0: None □ 1: Mild □ 2: Moderate □ 3: Pale or dark yellow complexion |
Irritability | □ 0: None □ 1: Occasional □ 2: Easily irritated, but able to gain self-control □ 3: Severe agitation, unable to gain self-control |
Numbness | □ 0: None □ 1: Hands and feet □ 2: Limbs □ 3: Entire body |
Edema | □ 0: None □ 1: Palpebral edema in the morning □ 2: Palpebral and lower limb edema □ 3: Extreme generalized edema (hyposarca) |
Frequency of urination at night | □ 0: None □ 1: 2 times □ 2: 3 to 4 times □ 3: 5 times or more |
Constipation | □ 0: None □ 1: Hard stools and straining □ 2: Hard stools with a 2 to 3 days between bowel movements □ 3: Hard stools with 3 or more days between bowel movements |
Hematuria | □ 0: None □ 1: Yes |