Online Chinese Medicine Consultation | Remote TCM Diagnosis

TCM Consultation Form

Full Name:

Gender:

Age:

Country:

State/Province:

Address:

Email:

Phone:

Other Contact Methods:

Body Temperature:

Heart Rate:

Blood Pressure:

Duration of Condition:

Main Symptoms:

Hot/Cold Sensitivity

Chills or aversion to cold:

Aversion to wind:

Heat intolerance:

Alternating chills and fever:

External heat with internal cold:

Sweating

Perspiration:

Sweating locations:

Head

Headaches:

Dizziness or vertigo:

Neck stiffness:

Dry nose:

Nasal congestion:

Runny nose:

Clear or colored discharge:

Nose sores:

Mouth

Bitter taste:

Bad breath:

Tooth pain:

Thirst

Dry mouth or thirst:

Preference for cold or warm drinks:

Daily water intake:

Nausea/Vomiting

Nausea:

Vomiting:

Throat

Sore throat:

Dry throat:

Throat obstruction sensation:

Cough

Cough:

Productive cough:

Clear or colored phlegm:

Shortness of breath:

Ears

Ear congestion:

Hearing loss:

Tinnitus:

Body

Skin rashes or sores:

Body aches:

Low back pain:

Joint pain:

Restlessness:

Yellow complexion:

Abdominal fullness with body heaviness:

Dry mouth with dull complexion:

Generalized pain:

Chest & Heart

Irritability:

Palpitations:

Chest fullness:

Upper abdominal fullness with rising energy:

Restlessness with anxiety:

Shortness of breath:

Weak breathing:

Epigastric hardness:

Heart pain:

Upper abdominal pain:

Upper abdominal rigidity:

Hard painful upper abdomen:

Full non-painful upper abdomen:

Heart anxiety:

Heartburn:

Rising energy toward heart:

Heart pain with heat:

Ribside

Rib pain:

Ribside hardness:

Fluid sensation in ribside:

Abdomen

Abdominal pain:

Abdominal masses:

Lower abdominal pulsation:

Lower abdominal tension:

Borborygmus:

Back

Back pain:

Back cold sensitivity:

Limbs

Cold hands/feet:

Limited joint movement:

Leg cramps:

Heavy painful limbs:

Urination

Difficult urination:

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:

Hunger without desire to eat:

Sleep

Insomnia:

Frequent waking:

Sleepiness:

Mental State

Confusion:

Fever with delirium:

Lethargy:

Irritability:

Medical History

Previous medical conditions:

Cause

Known cause of illness:

Women's Health

Menstrual cycle regularity:

Menstrual blood color:

Blood clots:

Menstrual cramps:

Associated symptoms:

Vaginal discharge:

Discharge color:

Discharge amount:

Unusual 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 thin pulse:

Lifestyle

Bedtime:

Wake time:

Occupation:

Additional information:

Other notes: