First Set:

1. Basic Information (Fill in black font)Name Gender Date of Birth Year and Month Occupation Place of Birth Current Residence Marital Status 2. Basic ConstitutionHeight:____ cm.Weight______ kg.Heart Rate: _____ beats per minute.Blood Pressure:Low Pressure____ High Pressure____ (Do not write if uncertain)A. What is the most painful and obvious main symptom currently?Are there any other accompanying symptoms?

Answer:

B. How did it start?How long have you been ill?

Answer:

C. Have you had any previous illnesses?What treatments have you undergone?Any history of hospitalization, family history, or surgical history?

Answer:

D. What other symptoms do you have throughout your body? Please describe in detail.

Answer:

3. Detailed Inquiry into the Condition(1) Cold and Heat Conditions1. Aversion to Cold:Even near fire, adding clothes or blankets cannot alleviate the cold.2. Fear of Cold:Near fire, adding clothes or blankets can alleviate the cold.3. Particularly afraid of cold in summer.4. Particularly afraid of cold in winter.5. Feet are not warm while sleeping in winter (need to soak feet in hot water before bed to gradually warm up).6. Feet are cold all night while sleeping in winter (need thick blankets or electric heaters).

Answer:

2. Fever:1. Elevated body temperature.2. Normal temperature but feels hot.3. Feels hot in the afternoon or at night.4. Why is there fever in the afternoon?5. Five hearts (palms and soles) feel hot.6. Particularly afraid of heat in summer.7. Not afraid of heat in summer.8. Alternating cold and heat.9. High fever that does not subside.10. Low fever persists.

Answer:

(2) Sweating Conditions: 1. Usually sweats easily, especially after activity.2. Usually does not sweat.3. Sweats while sleeping.4. Sweats upon waking.5. Sweats only on the head.6. Sweats on the palms and soles.7. Sweats on one side of the body.

Answer:

(3) Head Conditions

1. Has acne.2. Dizziness.3. Headache.4. Tinnitus.5. Oral ulcers.6. Toothache.

Answer:

(4) Bowel Conditions

Stool:1. Diarrhea.2. Constipation.3. Pain around the anus.4. Not having a bowel movement for many days.5. Frequent bowel movements in one day.6. Stool is shapeless.7. Excessive gas.8. Stool is sticky, uncomfortable, and feels like it is descending.9. Burning sensation in the anus during bowel movements.

Answer:

Urine:1. Clear urine.2. Yellow urine.3. Difficulty urinating.4. Wants to urinate soon after drinking water.5. Incomplete urination, feels like needing to urinate again shortly after.6. No nocturia.7. Nocturia once.8. Nocturia twice.9. Nocturia more than twice.10. Pain or difficulty during urination.

Answer:

(5) Pain Conditions: 1. Nature of Pain:1. Distension pain.2. Stabbing pain.3. Cold pain.4. Burning pain.5. Dull pain.6. Cramping pain.7. Heavy pain.8. Empty pain.9. Soreness.10. Fixed pain.11. Wandering pain.

Answer:

2. Location of Pain:1. Top of the head.2. Left side of the head.3. Right side of the head.4. Forehead.5. Back of the head.6. Pain behind the sternum.7. Left rib pain.8. Rib pain.9. Bilateral rib pain.10. Upper abdomen (left, middle, right).11. Lower abdomen (left, middle, right).12. Waist (left, middle, right, bilateral).13. Joint pain (specify which one).14. Whole body pain.

Answer:

(6) Phlegm Conditions

1. No phlegm.2. White phlegm.3. Yellow phlegm.4. Excessive phlegm.5. Phlegm difficult to expel.6. Blood-streaked phlegm.

Answer:

(7) Skin Conditions

1. Dry.2. Has rashes.3. Normal.4. Swollen.5. Masses.6. Bruises.

Answer:

(8) Abdominal Conditions

1. Abdominal pain.2. Abdominal distension.

Answer:

(9) Complexion

1. Normal.2. Sallow.3. Pale yellow.4. Red.5. Cyanotic.6. Dark.7. Dull.

Answer:

(10) Dietary and Taste Conditions: 1. Diet:What do you eat for breakfast (fill in what you eat):

2. What do you eat for lunch:

3. What do you eat for dinner:

4. What have you eaten besides staple foods (biscuits, milk, health products, etc.) before and now:

5. Lifestyle Habits

Hobbies:

Main activities of the day:

Do you take a nap (11 AM – 1 PM):

Second Set:

Traditional Chinese Medicine Questionnaire

Consultation Time:	Name:	Age:	Gender:
Phone or QQ:	City:	Height:	Weight:
Main Symptoms (please describe in detail, no more than 3):
Other discomfort symptoms:
How did you get the current illness?When did it start?
What diseases have you had before and how were they cured?
Do you have bad breath:	Do you have dry mouth:	Do you feel thirsty:
Are you afraid of heat or cold:	Are your lips, eyes, and nose dry:	Do you have a strong thirst for cold drinks:
Have you used a lot of anti-inflammatory drugs:	Have you had any internal organ surgeries:	Have you used hormones for a long time:
Is your throat dry:	Temperature of hands and feet:	How is your appetite:
The following are mandatory items, please describe as clearly as possible:
Do you have belching, nausea, bowel sounds, or abdominal distension:	Do you have discomfort above the navel (what symptoms):
Do you have a feeling of fullness or hardness in the chest:	Do you have discomfort in the lower abdomen (what symptoms):
Bowel movement frequency (once a day, several times a day, several days once):	Stool color (black, yellow, white):
Stool shape (hard and formed, soft and shaped, loose and unformed, first hard then loose, hard like beads):
Urine (more, less, difficult, uncontrollable, yellow, white, frequent, infrequent):
Tongue Body (normal size, thin, thick, with teeth marks):
Tongue Coating (thin, little, thick, white, yellow, black):
Tongue Color (light red, pale white, red, red tip, red edges):
Oral Conditions (bitter, dry, sour, tasteless, ulcers, salivation):
Thirst Conditions (thirsty and drink a lot, thirsty but do not want to drink, thirsty and drink a lot but still thirsty, thirsty and drink):
Cold and Heat (afraid of heat in summer, not afraid of cold in winter; afraid of heat in summer, afraid of cold in winter; very afraid of cold in winter; afraid of cold in both summer and winter):
Sweating (sweats very little, night sweats, spontaneous sweating, sweats easily with movement):
Diet (more, less, likes cold, likes hot, likes warm, likes sour, likes spicy, likes bitter, likes salty, likes sweet):
Food (more, less, likes rice, likes noodles, likes porridge, likes greasy, dislikes greasy, likes light, likes dry):
Fatigue (energetic, not easily fatigued; easily fatigued, drowsy and weak; sore waist and knees, dislikes activity; breathless with movement):
Sexual Activity (yes, no, many, few, hyperactive, impotence, premature ejaculation, masturbation, previous abortion):
Menstruation (early, late, heavy, light, dark, red, light, thick, thin, with clots, dysmenorrhea, leakage):
Leukorrhea (present, absent, more, less, white, yellow, fishy, foul):	Legs (pain, soreness, heaviness, numbness, swelling, cold, hot, soft, none):
Complexion (red, yellow, white, black, green):	Lip Color (light red, dark red, purple, black):
Head (pain, dizziness, numbness, heaviness, none):	Heart (anxiety, palpitations, panic, pain, timid):
Chest (fullness, oppression, distension, pain, none):	Ribs:(fullness, oppression, distension, pain, none):
Waist (soreness, heaviness, pain, cold, hot, distension, none):	Abdomen (swelling, distension, pain, fullness, none):
Current Chinese patent medicine or Western medicine being taken and reactions after taking:
Diagnosis:
Remarks:
Prescription from TCM:
Initial Prescription:

Classification	Signs	Normal Standards	Excess or Deficiency	√	Organ Differentiation
1	Sleep	Sleep through the night	Interrupted sleep, restless sleep	Liver not storing blood or heart blood deficiency, spirit not returning to the heart,
Often wakes up between 1-3 AM	Liver Yin deficiency forming or has formed
Often wakes up between 3-5 AM	Lung Yin deficiency forming or has formed
2	Appetite	Has appetite, food tastes good	Excessive	Yangming channel heat or influenced by steroid medication
No appetite	Spleen damage
No taste in food	Pancreas damage
3	Bowel Movements	Daily, stool is formed, soft and hard is moderate	Loose	Water and drink in the middle burner and intestines
Hard	Yangming organ excess
Diarrhea with clear liquid	Spleen Yang deficiency
4	Urine	Pale yellow	Yellow	Intestines still have dry stool
Clear	Internal cold, insufficient heat in the small intestine.
Frequent urination	Kidney Yang deficiency
5	Sweating	Easy to sweat in hot weather or with exercise	Excessive sweating, night sweats	Exterior Yang deficiency, unable to consolidate the exterior
No sweating	Heart function impaired, leading to heart not governing the five fluids
6	Thirst	Occasionally	No thirst	Water and drink stopped in the upper burner or unclean food remains in the stomach
Thirsty, drinks a thousand cups but still thirsty	Yangming channel heat or Kidney Yang deficiency causing metal not to generate water
Thirsty, wants to drink cold water	Internal heat
Thirsty, wants to drink warm water	Internal cold
7	Temperature of Feet	Warm	Cold	Heart Yang deficiency, insufficient heat in the heart moving to the small intestine
8	Body Cold and Heat Conditions	No special feeling	Whole body is cold	Yang deficiency
Upper heat and lower cold	Yin and Yang separation
Cold and heat alternating	Yin and Yang clashing
Whole body feels hot	Yang not entering Yin (long-term low fever)
9	Physical Strength	Good	Poor, easily fatigued	Heavenly Yang deficiency, causing Lung Yang unable to reach the Kidney.Congenital Kidney Yang deficiency.Thus feeling fatigued all over
10	Menstruation	Regular every month, no discomfort	Menstruation early	Internal heat	Menstruation is like breast milk, when heart Yang is insufficient, the milk that stays in the lungs cannot be fully or timely delivered to the uterus, leading to delayed menstruation being internal cold, early menstruation being heat syndrome, dysmenorrhea or clots being internal cold phenomena
Menstruation delayed	Internal cold
Dysmenorrhea or clots	Internal cold

Self-diagnosis of pulse conditions reference

Floating pulse, felt with light pressure, deep pulse, felt with heavy pressure, slow pulse, three beats per breath, rapid pulse, six beats per breath (one breath in and out is one breath)

Weak pulse, no strength in three positions, strong pulse, strength in three positions, large pulse, should feel surging and broad, slow pulse, should feel gentle,

Long pulse, over three fingers, short pulse, less than three fingers, slippery pulse, flowing smoothly, rough pulse, difficult to flow,

Surging pulse, surging and strong, tight pulse, rapid and erratic, thin pulse, narrow and not thick, faint pulse, vague and not obvious,

Hollow pulse, floating and large with a hollow center, wiry pulse, straight and strong, leather pulse, floating and extremely strong, solid pulse, deep and extremely strong,

Weak pulse, floating and thin with no strength, weak pulse, deep and thin with no strength, moving pulse, swaying at the joints, hidden pulse, sinking deep into the bones,

Rapid pulse, rapid with intermittent stops, knotted pulse, slow with intermittent stops, intermittent pulse, stops with a fixed interval, scattered pulse, erratic in and out,

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