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| 0 | 1 | 2 | 3 | TCM ZHENG measured |
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| (1) I have become fretful and irritated about everything. | □ | □ | □ | □ | Yin-Xu |
| (2) I have heartburn. | □ | □ | □ | □ | Yin-Xu |
| (3) I have been suffering from insomnia. | □ | □ | □ | □ | Yin-Xu Blood-Xu |
| (4) It takes a long time for me to fall asleep. | □ | □ | □ | □ | Yin-Xu Blood-Xu |
| (5) My hands and feet are warm. | □ | □ | □ | □ | Yin-Xu |
| (6) I have night sweat even if it’s not hot. | □ | □ | □ | □ | Yin-Xu |
| (7) I’m always thirsty. My throat feels completely dried out soon after I drink. | □ | □ | □ | □ | Yin-Xu |
| (8) I have to get up to pee at night. | □ | □ | □ | □ | Yang-Xu |
| (9) I urinate a lot, and the color of my urine is faint. | □ | □ | □ | □ | Yang-Xu |
| (10) I feel cold when others feel cool and comfortable. | □ | □ | □ | □ | Yang-Xu |
| (11) I wear more layers because I feel cold. | □ | □ | □ | □ | Yang-Xu |
| (12) I like to stay in a warm place and like to huddle up to feel warm. | □ | □ | □ | □ | Yang-Xu |
| (13) I have loose stools. | □ | □ | □ | □ | Yang-Xu |
| (14) I feel very tired after mild activity. | □ | □ | □ | □ | Qi-Xu |
| (15) I feel dizzy when getting up quickly. | □ | □ | □ | □ | Qi-Xu Blood-Xu |
| (16) I do not like to talk because I soon feel tired after saying a few words. | □ | □ | □ | □ | Qi-Xu |
| (17) I still feel sleepy after a long sleep. | □ | □ | □ | □ | Qi-Xu |
| (18) I feel lightheaded. | □ | □ | □ | □ | Qi-Xu Blood-Xu |
| (19) I sweat even if it is cool. | □ | □ | □ | □ | Qi-Xu |
| (20) I get out of breath when I walk a little. | □ | □ | □ | □ | Qi-Xu |
| (21) I feel palpations even when still or peaceful. | □ | □ | □ | □ | Blood-Xu |
| (22) I am neither nearsighted nor farsighted (or has already been corrected), but I still have blurred vision. | □ | □ | □ | □ | Blood-Xu |
| (23) My body and limbs feel numb when I keep still. | □ | □ | □ | □ | Blood-Xu |
| (24) My ears ring when it is quiet. | □ | □ | □ | □ | Blood-Xu |
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