TCM consultation form (use the computer version of WeChat, click and open the inquiry form, fill in the computer carefully)

=========Profile ===============

Patient Name:                  Age：            Gender:                       WeChat:

Recipient Address:

Recipient's Phone:                                                  

=========The condition part ==============

Main symptoms, onset time, after and cause:

 

 

=========Medical part ==============

Other discomforts, time, passage and causes:

 

 

========= Past History ==============

Allergies:                                     Genetic diseases:

Medicine currently using:

Chronic history or major medical history:

========= Syndrome (patient self-feeling discomfort) ==============

Note: Please fill in the answer in front, you can choose multiple options. If there are other situations, please add them yourself without any restrictions. If privacy is involved, or no abnormalities are found, leave it blank.

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Tongue:

( ) 1. Tongue color:    A reddish.    B bright red.   C. Purple    D. Blush   E. Tongue red

( ) 2. Tongue:    A fat/big      B. Thin/small     C. Normal size

( ) 3. Tongue Moss :   A. More     B. Less     C. Moderate      D. No moss    E. Yellow          F. White G. Black

( ) 4. Concentrated area of ​​Moss:    A middle    B. Rear     C. Front    D. Even distribution

​

Please provide a photo of the upper part of the tongue and the sublingual vein to make up for the lack of pulse diagnosis.

 

() Gynecology: Menstruation

( ) 1. Menstrual cycle:   A. Earlier    B. Delayed      C. Unscheduled      D. Normal 28-30 days

( ) 2. Menstrual time:    A. Short 1-3 days     B. Length 5-8 days      C. Normal 5 days

( ) 3. Volume:     A. More     B. Less      C. Normal         D. Amenorrhea

( ) 4. Menstrual color:    A. Dark          B. Light       C. Fresh red        D. Black, with blood clots

() 5. Accompanying:       A. breast pain      B. Dysmenorrhea        C. back discomfort     D. dizziness

( ) 6. Recent production conditions:     A. Pregnancy      B. Abortion          

( ) 7. leucorrhea:    A. more     B. less             C. clear          D. yellow         E. odor

 

() Male:   A. Impotence         B. Premature ejaculation     C. Normal     D. Scrotum wet E. Morning berth, strong or weak

( ) Cold/heat:    A. Fear of heat   B. Fear of cold   C. Hand and feet cold    D. Hand and feet  hot     E.Hot flash

( ) Head:    A. Dizziness     B. Headache     C. Tinnitus     D. Oral ulcers    E. Toothache    F. Degeneration of gums

() chest and abdomen:    A. chest pain and tightness     B. flustered heart    C. flank pain    D. stomach pain

( ) Breathing:    A. Asthma      B. Asthma       C Cough

() Waist:   A. Low back pain      B. Backache

( ) Skin:  A dry     B has sore rash     C normal         D edema       E skin disease    F. Skin itchy

() Abdomen:   A. Abdominal pain         B bloating

( ) Face color;   A normal     B chlorosis     C white yellow      D red         E green        F black        G dark

() urination:     A. frequent urination during the day       B. urinary incontinence    C. clear urine    E. orange urine  

                         F. chyluria G. noctoria

( ) Stool:      A. It is thin.        B is more than one day.  C is dry.  D is more than one day.   E. difficult and powerless.

() Sweating::   A. Head sweat      B. Hand sweat         C foot sweat         D. Body sweat

() Sweating time:      A. Unscheduled       B. sweat whenever there is effort     C. Tidal sweat        D. Night sweat

( )Work and rest:    A. Physical labor     B. less physical activity     C. Weak

() Spirit:    A. Anxiety    B. depression    C. Irritability   D. Good mood

() Sleep:    A. Difficult to sleep       B. Long-term insomnia     C. Easy to wake up early, wake up after sleep,

( )Spit color:    A no flaw    B  white    C痰 yellow    D痰 more    E  spit with blood

( ) Diet:    A particular for food     B normal     C no appetite    D. vomiting    E often burp

() Drinking:     A less drink     B hot drink      C like cold drink      D normal drinking water

 

=========End line ============

 

Patient note:

 

Attachment: Hospital diagnosis / discharge certificate