TCM Questionnaire

Choose the correct symptoms for yourself. The most urgent health problems need to be solved at present, such as high blood pressure, diabetes, migraine etc. Name: Gender: Age: Weight : Height:

Medical history: What diseases have you had before? When? What treatment did you take? How about the effects?

1. How would you describe your body type? Tall Medium height Short Lean Medium Burly Overweight Underweight

2. Appetite 1. Have a good appetite?

Yes

No

2. Have no appetite? Yes No 3. Eat at regular times? Yes No 4. Snack between meals? Yes No 5. Get hungry quickly after eating and want to eat more? Yes No 6. Get hungry, but have no desire to eat? Yes No 7. Have addiction to certain foods? No Yes Which foods 8. Do you feel dry in your mouth? Yes No 9. Do you feel bitter in your mouth? Yes No 10 What kind of predominant flavor do you like? Neutral Sweet Sour Bitter Pungent ( spicy ) Salty astringent 11. How about your digestion? Good 12. Do you have nausea? Yes No Just So So Bad

stick and greasy Other:

3. Drink
1. Are you thirsty often? Yes No 2. Never thirsty? Yes No 3. Feel better after drinking? Yes No 4. What drinks do you like? Hot drinks

Cold drinks

4. Sleep
1. Do you suffer from insomnia? Yes No Yes No 2. Is your sleeping light or deep? Light Deep 3. Is your sleep easily disturbed, either by outside influences or dreams or other? 4. Once awake, is it hard to go back to sleep? Yes No Yes No

5. If you wake up during the night regularly, does this happen on a particular time? 6. Do you suffer from drowsiness, or feeling sleepy during the day? Yes No

5. Perspiration
1. Do you easily sweat? Yes No 2. Feel cold while sweating? Yes No 3. Feel hot while sweating? Yes No 4. Will Sweat cause stain in the clothes Yes No 5. If so, what color of the stain: Yellow Red Black 6. If sweating is in a certain body location, please indicate: Head Torso chest back Palms Soles of feet Other:

Other color

6. Temperature
1. Do you often feel hot? Yes No 2. When do you feel hot? in the morning in the afternoon in the evening

3. Do you generally feel cold? Yes No 4. Do you strongly feel cold or slightly feel cold? 5. Are cold hands and feet a common occurrence?

Strongly Slightly Yes No

7. Urine
1. How would you describe your urine? Clear color Light yellow Dark yellow 2. What is the odor of the urine? Strong odor 3. Time of urination: Long Short 4. Do you have retention of urine regularly? Yes 5. Night urination or not? No Yes 6. If yes, how many times about the night urination? 6. Any other comments: Blood in urine Muddy urine. Light odor No odor No times per night

8. bowels
1. How about your defecation? How many times per day or how many days for one time? Your answer:

2. How about your description of the bowels? (Choose the following answers fit for you) Loose bowels 3. Is there any undigested food in stool Yes 4. Is defecation painful? Yes No 5. Constipation? Yes No 6. Any other comments: No Dry and hard Water like Blood in bowels Black bloody bowels thick bloody

9. Sexual Function for Male

A. spermatorrhoea B. impotence C. not hard during erection D. not last long during hardness E. unable of sexual intercourse

10. Menstruation for Female

1. Year of your first menstruation: 2. Menstrual cycle: .days 3. Length of menstruation: days 4. How long since your amenorrhea 5. Do you have an irregular cycle? 6. How about the measure during menstruation? A. scanty menstruation B. profuse menorrhea C. metrorrhagia and metrostaxis 7. Is there any other following menstrual condition? A. menstruation with light color and thin texture B. menstruation with deep-red color and sticky texture C. dark purple menstrual color D. menstruation with blood clot 8. Do you have preceded menorrhea or delayed menorrhea? How many days? 9. Do you feel painful in the abdomen during menstruation? 10. If so, when do you feel painful? A. before menstruation B. during menstruation C. after menstruation 11. How about the pain in the lower abdomen during menstruation? Yes No

A. dull pain B. stabbing pain C. distending pain 11. How about the leucorrhea? A. Profuse leucorrhea with white color, thin texture and odorless B. leucorrhea with yellow color; sticky texture and foul C. leucorrhea with red color like mixed blood D. leucorrhea reddish or whitish 12. Do you have lumbago during the menstruation? If yes, how do you describe it? Yes No

11. About Pain

1. If you experience pain, could you describe the location: A. Head B. Upper chest C. Lower chest D. gastric cavity E.pain around the navel F. Lower abdomen G. Upper back H. Lower back I. Inside of arms J. Outside of arms K. Hands L. Inside legs Upper or Lower M. Outside legs Upper or Lower N. Feet O. Whole body P. Other part: 2. Does the pain stay in one location or does it move around? 3. Is it acute and sharp? Acute pain Sharp pain 4. Is it a sharp pain, which one belongs to? A. aching pain B. vague pain C. another description of the pain: 5. Does the pain come and go, or is it steady? Come and go Steady 6. How long have you had this pain condition? 7. And how many periods per day?

12. About Ears

1. Does your ears have any of the following symptoms: Tinnitus Deafness Blocked ear 2. Any other comments about the ear:

13. About Eyes

1. Does your eyes have any of the following symptoms: Itchy eye(s) Intolerance of light Pain of the eye 2. Are your eyes bloodshot (red) often? Yes No 3. Any other comments about the eyes: Eye tearing Dizzy vision

14. About Face description

1. How about the color of your face? Reddish Red Yes No Pale Pale yellowish dark bluish Purplish dry lip 2. How about the condition of your lips? 3. Do your cheeks have red blotches?

4. Are your eye sockets sunken? Yes 5. Is the area around the eyes dark? Yes 6. Are your face and eyes dropsy? Yes

No No No

15. About Tongue descriptions

How would you describe your tongue? A. Body of tongue soft and can not stretch B. tongue flexes and lolls without rigidity C. Tongue moves involuntarily to one side D. Body of tongue trembles E. Other Comments:

16. About Cough and Phlegm

1. Do you have a cough? Yes No 2. If yes, please answer the following questions: 1) Do you have a dry cough without phlegm? Yes 2) Do you have a cough with phlegm? Yes No 3) Is it easy to cough up the phlegm and discharge it? 4) Do you feel itch in your pharynx? Yes No 3. How about the description of the phlegm: A. Yellow and thick phlegm B. Copious sticky plegm C. Little sticky phlegm D. Copious white phlegm E. White and thin phlegm F. phlegm with brilliant blood color G. phlegm fishiness H. Any other comments:

No Yes No

17. About Hair

How would you describe your hair condition? A. Yellow and dry B. Itch and many greasy knots C. Hair loss D. Sparse hair E. White hair

18. The situation of current physical sense

Dizziness or vertigo, Nervous and Forgetful, Unresponsive, Irritability, Upset, Sleepy, Dry skin, Skin itch, Skin ulcer, Flustered and distraught, vomit Acid, turgor and discomfort in gastric cavity and abdomen, bulge and stuffy in gastric cavity and turgor in its flank, acroanesthesia, members tremble,

ache and weak in waist and knee, waist and leg. Bulge and tired, tremble, lump part

rigidity and vertical in waist, slowness in bend spread, ache in ponderosity in two legs, turgescence in foots and legs, two hands

19. Climate condition of the four seasons in your country: