Online TCM Consultation South Africa | Traditional Chinese Medicine Diagnosis

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Name :

Gender :

Age :

Country:

Province:

Address :

Email :

Phone :

Other Contact :

Temperature :

Heart Rate :

Blood Pressure :

Duration of Illness :

Main Symptoms :

Cold/Heat

Chills or cold intolerance :

Wind intolerance :

Heat intolerance :

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 :

Phlegm with cough :

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 :

Restlessness with anxiety :

Shortness of breath :

Weak breathing :

Epigastric hardness :

Heart pain :

Upper abdominal pain :

Upper abdominal rigidity :

Upper abdominal fullness with pain :

Upper abdominal fullness without pain :

Heart fear :

Heartburn :

Rising energy toward heart :

Heart pain with heat :

Ribs

Rib pain :

Rib stiffness :

Fluid sensation below ribs :

Abdomen

Abdominal pain :

Abdominal masses :

Lower abdominal pulsation :

Lower abdominal tension :

Abdominal rumbling :

Back

Back pain :

Back coldness :

Limbs

Cold hands/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 :

Sleepiness :

Mental State

Confusion :

Fever with delirium :

Fatigue with drowsiness :

Irritability :

Medical History

Previous medical conditions :

Cause

Known cause of illness :

Female Menstruation

Period regularity :

Menstrual color :

Blood clots :

Menstrual pain :

Other discomforts :

Vaginal discharge :

Discharge color :

Discharge amount :

Discharge odor :

Breast tenderness :

Tongue Color

Tongue color :

Facial Color

Normal complexion :

Red face :

Pale face :

Bluish face :

Dark face :

Pulse

Superficial pulse :

Tight pulse :

Full pulse :

Deep pulse :

Slippery pulse :

Weak thin pulse :

Daily Routine

Sleep time :

Wake time :

Occupation :

Other symptoms :

Additional notes :

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