TCM Health Assessment Form
Name :
Gender :
Age :
Country:
Province:
Address :
Email :
Phone :
Other Contact :
Body Temperature :
Heart Rate :
Blood Pressure :
Duration of Illness :
Main Symptoms :
Chills & Fever
Chills or feeling cold :
Sensitivity to wind :
Feeling hot :
Alternating chills and fever :
External heat with internal cold :
Sweating
Sweating :
Sweating locations :
Head
Headache :
Dizziness :
Neck stiffness :
Dry nose :
Nasal congestion :
Runny nose :
Clear or turbid nasal discharge :
Nose sores :
Mouth
Bitter taste :
Bad breath :
Toothache :
Thirst
Thirst or dry mouth :
Prefer cold or warm drinks :
Water intake :
Vomiting
Nausea :
Vomiting :
Throat
Sore throat :
Dry throat :
Throat obstruction feeling :
Cough
Cough :
Cough with phlegm :
Clear or turbid phlegm :
Shortness of breath :
Ears
Ear congestion :
Hearing loss :
Tinnitus :
Body
Skin rashes or sores :
Body pain :
Back pain :
Joint pain :
Restlessness :
Yellowish skin :
Abdominal fullness with body heaviness :
Dry mouth with dull facial expression :
General body pain :
Chest & Heart
Irritability :
Palpitations :
Chest fullness :
Upper abdominal fullness with rising energy :
Feelings of agitation :
Shortness of breath :
Low energy :
Epigastric hardness :
Heart pain :
Upper abdominal pain :
Upper abdominal rigidity :
Upper abdominal fullness with pain :
Upper abdominal fullness without pain :
Heart anxiety :
Heartburn :
Rising energy toward heart :
Burning chest pain :
Ribs
Rib pain :
Rib fullness and hardness :
Fluid retention under ribs :
Abdomen
Abdominal pain :
Abdominal masses :
Lower abdominal pulsation :
Lower abdominal tension :
Abdominal gurgling :
Back
Back pain :
Back chills :
Limbs
Cold hands and feet :
Difficulty moving limbs :
Leg cramps :
Heavy painful limbs :
Urination
Difficulty urinating :
Frequent urination :
Urgent urination :
Incontinence :
Urine color :
Urine volume :
Bowel Movements
Constipation :
Diarrhea :
Incomplete evacuation :
Sticky stool :
Blood or mucus in stool :
Digestion
Acid reflux :
Bloating :
Vomiting after eating :
Hungry but no appetite :
Sleep
Insomnia :
Easily awakened :
Drowsiness :
Mental State
Confusion :
Fever with delirium :
Fatigue with desire to sleep :
Irritability :
Medical History
Previous medical conditions :
Cause
Known cause of illness :
Women's Health
Menstrual cycle regularity :
Menstrual color :
Blood clots :
Menstrual cramps :
Other menstrual symptoms :
Vaginal discharge :
Discharge color :
Discharge amount :
Unusual odor :
Breast tenderness :
Tongue Color
Tongue color :
Facial 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
Bedtime :
Wake-up time :
Daily occupation :
Additional information :
Other notes :
