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Table 3 15-item questionnaire for the diagnosis of blood stasis with metabolic diseases

From: Effectiveness of Gyejibongnyeong-Hwan for shoulder pain: study protocol for a randomised, wait-list controlled pilot trial

Question Response Score
1. Angina pectoris No Yes 3 points
2. Having chest pain without angina pectoris No Yes
3. Blackish red tongue No Yes
4. Ecchymosis of tongue No Yes
5. Stabbing pain No Yes
6. Sublingual varicosities No Yes 2 points
7. Dark purple of palate mucosa No Yes
8. Blackish red lips No Yes
9. Blackish red gingiva No Yes
10. Chronic pain in joint/palsies and numbness No Yes
11. Pain at night No Yes
12. Bruised easily No Yes
13. Dark colouration of periocular region No Yes 1 point
14. A dark colouration of the face No Yes
15. Scaly and rough skin No Yes