Five Element Intake Form

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Transcription:

Five Element Intake Form (This check list is just a sampling of Five Element criteria that are used in diagnosis. You can use it by simply checking off those items that pertain to your constitution or your current problems and then adding up the results. The results will be a superfical, yet somewhat reliable, calculation and diagnosis. Complete diagnosis requires careful observation by a trained Doctor of Oriental Medicine, tongue and pulse diagnosis and a complete family and personal health history.) WATER ELEMENT tired between 3-5 p.m. hypoglycemia craves salt craves sugar craves a meat and potatoes with gravy diet like or dislike for the color dark blue or black has a black car wears predominantly black clothes urinary tract infections little sex drive premature ejaculation prostate inflammation prostate cancer dark circles under the eyes bad hearing dizziness afternoon headaches low energy in general needs to snack frequently fear is a primary emotion or motivating factor in life fears change fears sex fears the dark clostrophobia weak or painful knees losing hair dislike for cold or rainy weather vaginal discharge

vaginal pain painful sexual intercourse menstral difficulty poor will power and follow through difficulty sticking to your diet dreams of drowning people, plunging into water or of boats Total Water WOOD ELEMENT dislike for the wind, especially dislike the Santa Ana winds angers easily flies off the handle like or dislike for the color green likes fatty or fried foods a lot craves cheese flatulence burping heartburn poor eyesight or wears glasses like or dislike for sour foods (sweet tarts, vinegar, pickles, sourkraut, etc.) voice is of a shouting nature family history of gall bladder problems acne alcoholic mother or father you drinks too much alcohol menstral cramps pre-menstral symptoms insomnia, can't get to sleep, or hyper between 11 p.m. and 1 a.m. an "idea" person starts projects easily, but trouble following through arthritis or joint pain pain in the right shoulder blade pain in the right shoulder pain in the right eye or left eye radiating from the back of the head nightmares of being trapped feelings of being smothered overly organized difficulty planning difficulty making decisions muscle spasms epilepsy or convulsions

M.S. cystic breasts warts moles freckles cysts fibroids family history of cancer dreams of mountain forests or trees Total Wood FIRE ELEMENT very warm person emotionally difficulty getting close to people very protected emotionally always laughing and giggling heartburn flatulence a few hours after eating dislike for the heat of summer or loves the heat of summer stuttering perspiration: either too much or not at all like or dislike for the color red red car wears red clothing a lot emotional problems dreams of fire, laughing, or blazing flames red complexion hot flashes poor circulation cold a lot more than others high blood pressure Total Fire EARTH ELEMENT feels connectedness with the earth very grounded stubborn overweight

underweight anorexic bulemia homesick or difficulty leaving home constantly thinks about the past obsessive compulsive feels alone a lot feels a sense of disconnection from life in general likes or dislikes the color yellow yellowish complexion stomach pains ulcers stomach gas right after eating constant stomach troubles hypoglycemia fatigue after eating diabetic inability to receive sympathy has a monotone voice has a singing voice likes to sing a lot belching after eating dislike for dampness arthritis which is worse in damp weather dreams of lack of food or drink, singing or building buildings craves sweets dislike for sweets Total Earth METAL ELEMENT pale face white skin white automobile wears white clothing a lot looks good in white allergies lots of colds and flu hay fever constipation or diarrhea a lot must use laxatives

chronic bronchitis asthma skin rash eczema psoriasis dry skin very sad a lot constantly dwelling on the loss of a loved one cries at the drop of a hat never cries difficult to feel any emotions grieving over a recent sad event likes hot and spicy foods likes or dislikes the color white worries a lot shortness of breath emphasema smoker or got a lot of passive smoke growing up sighs a lot acne boils post nasal drip dreams of white objects, cruel killing, crying, flying in the air Total Metal Compliments of Dr. Randy Martin, www.drrandymartin.com

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