TCM Consultation Form
Full Name :
Gender :
Age :
Country:
Region/County:
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 or feverish :
Alternating chills and fever :
External heat with internal cold :
Perspiration
Presence of sweating :
Areas of sweating :
Head
Headache :
Dizziness or vertigo :
Stiff neck or back :
Dry nose :
Nasal congestion :
Runny nose :
Clear or thick nasal discharge :
Sores under nose :
Mouth
Bitter taste in mouth :
Bad breath :
Toothache :
Thirst
Thirst or dry mouth :
Preference for cold or warm drinks :
Amount of fluid intake :
Vomiting
Nausea :
Vomiting :
Throat
Sore throat :
Dry throat :
Feeling of lump in throat :
Cough
Cough :
Phlegm with cough :
Clear or thick phlegm :
Wheezing or shortness of breath :
Ears
Blocked ears :
Hearing loss :
Tinnitus (ringing in ears) :
Body
Skin rashes or sores :
Body aches :
Lower back pain :
Joint pain :
Restlessness :
Yellowish skin :
Abdominal fullness and heavy body :
Dry mouth and dull complexion :
General body pain :
Chest & Heart
Irritability :
Palpitations :
Chest tightness :
Fullness below heart with rising energy :
Feelings of agitation :
Shortness of breath :
Lack of energy :
Hard lump below heart :
Heart pain :
Pain below heart :
Rock-hard feeling below heart :
Fullness, hardness and pain below heart :
Fullness without pain below heart :
Heart anxiety :
Heartburn :
Rushing energy towards heart :
Pain and heat in heart region :
Ribs
Rib pain :
Hard lump below ribs :
Fluid below ribs :
Abdomen
Abdominal pain :
Abdominal masses :
Pulsation below navel :
Acute lower abdominal pain :
Borborygmus (stomach rumbling) :
Back
Back pain :
Cold back :
Limbs
Cold hands and feet :
Stiff joints :
Leg cramps :
Heavy, painful limbs :
Urination
Difficulty urinating :
Frequent urination :
Urgent need to urinate :
Incontinence :
Urine colour :
Urine volume :
Stool
Constipation :
Diarrhoea :
Incomplete evacuation :
Sticky stool :
Blood or mucus in stool :
Digestion
Acid reflux :
Bloating :
Vomiting after eating :
Hungry but no appetite :
Sleep
Difficulty falling asleep :
Easily woken :
Sleepiness :
Mind
Confusion :
Fever with delirium :
Lethargy :
Irritability :
Medical History
Previous medical conditions :
Cause
Known cause of illness :
Women's Health (Menstruation)
Cycle: regular, early, late, or irregular :
Colour of menstrual blood :
Blood clots :
Menstrual cramps :
Other discomfort during period :
Vaginal discharge :
Colour of discharge :
Amount of discharge :
Odour :
Breast tenderness :
Tongue Colour
Tongue colour :
Complexion
Normal complexion :
Red complexion :
Pale complexion :
Bluish complexion :
Dark complexion :
Pulse
Superficial pulse :
Tight pulse :
Full pulse :
Deep pulse :
Slippery pulse :
Faint pulse :
Lifestyle
Bedtime :
Wake-up time :
Occupation :
Other information :
Additional notes :
