TCM Consultation Form
Name :
Gender :
Age :
Country:
Region:
Address :
Email :
Phone :
Other Contact Methods :
Body Temperature :
Heart Rate :
Blood Pressure :
Duration of Illness :
Main Condition :
Chills and Fever
Chills or Fear of Cold :
Fear of Wind :
Fear of Heat :
Alternating Chills and Fever :
Heat in Exterior, Cold in Interior :
Sweating
Sweating :
Sweating Areas :
Head
Headache :
Dizziness or Vertigo :
Stiff Neck and Back :
Dry Nose :
Nasal Congestion :
Runny Nose :
Clear or Turbid Nasal Discharge :
Sores Under Nose :
Mouth
Bitter Taste in Mouth :
Bad Breath :
Toothache :
Thirst
Thirst or Dry Mouth :
Preference for Cold or Hot Drinks :
Water Intake :
Vomiting
Retching :
Vomiting :
Throat
Sore Throat :
Dry Throat :
Foreign Body Sensation in Throat :
Cough
Cough :
Cough with Phlegm :
Clear or Turbid Phlegm :
Persistent Wheezing :
Deafness
Blocked Ears :
Deafness :
Tinnitus :
Body
Skin Sores or Rashes :
Body Aches :
Lower Back Pain :
Joint Pain :
Restlessness :
Jaundice :
Abdominal Fullness, Heavy Body, Difficulty Turning :
Dry Mouth, Unrecognizable Face :
Body Pain :
Chest and Heart
Irritability :
Palpitations :
Chest Fullness :
Rebellious Qi Rising to Chest :
Feelings of Agitation :
Shortness of Breath :
Lack of Energy :
Hard Lump Below Heart :
Heart Pain :
Pain Below Heart :
Stone-like Hardness Below Heart :
Fullness, Hardness, and Pain Below Heart :
Fullness Without Pain Below Heart :
Fear :
Heartburn :
Qi Rushing Up to Heart :
Burning Pain in Heart :
Ribs
Rib Pain :
Hard Lump Below Ribs :
Fluid Below Ribs :
Abdomen
Abdominal Pain :
Abdominal Hard Mass :
Palpitations Below Navel :
Acute Lower Abdominal Pain :
Borborygmus (Stomach Rumbling) :
Back
Back Pain :
Back Fear of Cold :
Limbs
Cold Hands and Feet :
Difficulty Flexing and Extending Limbs :
Cramping in Feet :
Heavy, Painful Limbs :
Urination
Difficulty Urinating :
Frequent Urination :
Urgent Urination :
Enuresis (Bedwetting) :
Urine Color :
Urine Volume :
Bowel Movements
Constipation :
Diarrhea :
Incomplete Evacuation :
Sticky Stool :
Blood or Pus in Stool :
Diet
Acid Reflux :
Bloating :
Vomiting After Eating :
Hungry But No Desire to Eat :
Sleep
Insomnia, Difficulty Falling Asleep :
Easily Woken :
Somnolence (Sleepiness) :
Spirit
Unclear Mind :
Fever and Delirium :
Fatigue and Desire to Sleep :
Irritability :
Past Illness
History of Past Illness :
Cause
Known Cause of Illness :
Female Menstruation
Menstrual Cycle: Normal, Early, Late, or Irregular :
Menstrual Color :
Blood Clots :
Menstrual Cramps :
Other Discomfort :
Vaginal Discharge :
Discharge Color :
Discharge Volume: Heavy or Light :
Odor :
Breast Distension :
Tongue Color
Tongue Color :
Complexion
Normal Complexion :
Red Complexion :
Pale Complexion :
Bluish Complexion :
Dark Complexion :
Pulse
Floating Pulse :
Tight Pulse :
Full and Large Pulse :
Deep Pulse :
Slippery Pulse :
Faint and Thin Pulse :
Daily Routine
Bedtime :
Wake-up Time :
Daily Work :
Other Explanations :
Other Remarks :
