Online Chinese Medicine Consultation NZ | YouTCM Remote TCM Diagnosis

TCM Health Assessment Form

Full Name :

Gender :

Age :

Country:

Region:

Address :

Email :

Phone :

Other Contact :

Body Temperature :

Heart Rate :

Blood Pressure :

Duration of Condition :

Main Symptoms :

Heat & Cold

Chills or feeling cold :

Sensitivity to wind :

Feeling hot or heat intolerance :

Alternating chills and fever :

External heat with internal cold :

Perspiration

Sweating :

Areas of sweating :

Head

Headache :

Dizziness or vertigo :

Neck or back stiffness :

Dry nose :

Nasal congestion :

Runny nose :

Clear or thick nasal discharge :

Nose sores :

Mouth

Bitter taste in mouth :

Bad breath :

Toothache :

Thirst

Thirst or dry mouth :

Preference for cold or warm drinks :

Daily water intake :

Vomiting

Nausea :

Vomiting :

Throat

Sore throat :

Dry throat :

Feeling of obstruction in throat :

Cough

Cough :

Phlegm with cough :

Clear or thick phlegm :

Shortness of breath :

Ears

Blocked ears :

Hearing difficulty :

Tinnitus :

Body

Skin rashes or sores :

Body aches :

Back pain :

Joint pain :

Restlessness :

Yellowish skin :

Abdominal fullness with body heaviness :

Dry mouth with dull complexion :

General body pain :

Chest & Heart

Irritability :

Palpitations :

Chest fullness :

Feeling of upward rushing energy :

Feeling of agitation :

Shortness of breath :

Lack of energy :

Hardness below heart :

Heart pain :

Pain below heart :

Hard mass below heart :

Hard painful mass below heart :

Fullness without pain below heart :

Heart anxiety :

Heartburn :

Upward衝撞 to heart :

Burning pain in heart :

Ribs

Rib pain :

Hardness below ribs :

Fluid below ribs :

Abdomen

Abdominal pain :

Abdominal masses :

Pulsation below navel :

Acute lower abdominal pain :

Borborygmus :

Back

Back pain :

Cold back :

Limbs

Cold hands and feet :

Difficulty moving limbs :

Leg cramps :

Heavy painful limbs :

Urination

Difficulty urinating :

Frequent urination :

Urgent urination :

Incontinence :

Urine colour :

Urine volume :

Bowel Movements

Constipation :

Diarrhoea :

Incomplete evacuation :

Sticky stool :

Blood or mucus in stool :

Digestion

Acid reflux :

Bloating :

Vomiting after eating :

Hunger without desire to eat :

Sleep

Difficulty falling asleep :

Easily awakened :

Sleepiness :

Mental State

Confusion :

Fever with delirium :

Lethargy :

Irritability :

Medical History

Previous medical conditions :

Causes

Known causes of illness :

Women's Health

Menstrual cycle regularity :

Menstrual colour :

Blood clots :

Menstrual pain :

Other menstrual symptoms :

Vaginal discharge :

Discharge colour :

Discharge amount :

Discharge odour :

Breast tenderness :

Tongue

Tongue colour :

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 time :

Occupation :

Additional information :

Other notes :

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