Online Chinese Medicine Consultation Australia | Telehealth TCM Diagnosis

TCM Health Assessment Form

Full Name:

Gender:

Age:

Country:

State/Territory:

Address:

Email:

Phone:

Other Contact:

Body Temperature:

Heart Rate:

Blood Pressure:

Duration of Condition:

Main Symptoms:

Heat/Cold Sensitivity

Chills or cold intolerance:

Wind sensitivity:

Heat intolerance:

Alternating chills and fever:

External heat with internal cold:

Perspiration

Sweating:

Sweating locations:

Head

Headaches:

Dizziness:

Neck/back stiffness:

Dry nose:

Nasal congestion:

Runny nose:

Clear or thick nasal discharge:

Nose sores:

Mouth

Bitter taste:

Bad breath:

Toothache:

Thirst

Dry mouth/thirst:

Prefer cold or warm drinks:

Daily fluid intake:

Nausea/Vomiting

Nausea:

Vomiting:

Throat

Sore throat:

Dry throat:

Throat obstruction sensation:

Cough

Cough:

Phlegm with cough:

Clear or thick phlegm:

Wheezing:

Ears

Ear congestion:

Hearing loss:

Tinnitus:

Body

Skin rashes/sores:

Body pain:

Back pain:

Joint pain:

Restlessness:

Yellow complexion:

Abdominal fullness with body heaviness:

Dry mouth with dull complexion:

General body pain:

Chest/Heart

Irritability:

Palpitations:

Chest fullness:

Upper abdominal fullness with rising energy:

Restless feeling:

Shortness of breath:

Weak breathing:

Epigastric rigidity:

Heart pain:

Upper abdominal pain:

Upper abdominal hardness:

Hard painful upper abdomen:

Full non-painful upper abdomen:

Heart anxiety:

Heartburn:

Rising energy toward heart:

Burning heart pain:

Ribs

Rib pain:

Rib stiffness:

Fluid sensation in ribs:

Abdomen

Abdominal pain:

Abdominal masses:

Lower abdominal pulsation:

Lower abdominal tension:

Abdominal rumbling:

Back

Back pain:

Back coldness:

Limbs

Cold hands/feet:

Limited joint movement:

Leg cramps:

Heavy painful limbs:

Urination

Urination difficulty:

Frequent urination:

Urgent urination:

Incontinence:

Urine color:

Urine volume:

Bowel Movements

Constipation:

Diarrhea:

Incomplete evacuation:

Sticky stool:

Blood/mucus in stool:

Digestion

Acid reflux:

Bloating:

Vomiting after eating:

Hunger without appetite:

Sleep

Insomnia:

Easy waking:

Sleepiness:

Mental State

Confusion:

Fever with delirium:

Lethargy:

Irritability:

Medical History

Previous conditions:

Causes

Known causes:

Women's Health

Menstrual regularity:

Menstrual color:

Blood clots:

Menstrual pain:

Associated symptoms:

Vaginal discharge:

Discharge color:

Discharge amount:

Discharge odor:

Breast distension:

Tongue

Tongue color:

Complexion

Normal complexion:

Red complexion:

Pale complexion:

Bluish complexion:

Dark complexion:

Pulse

Superficial pulse:

Tight pulse:

Full pulse:

Deep pulse:

Slippery pulse:

Weak pulse:

Lifestyle

Sleep time:

Wake time:

Occupation:

Additional information:

Other notes: