Name :
Gender :
Age :
Country:
Address :
Email :
Phone Number :
Other contact methods :
Body temperature :
Heart rate :
Blood pressure :
Duration of illness :
state of illness :
Fever and chills
Whether Fear of cold :
Whether Afraid of the wind :
Whether Fear of heat :
Whether alternating fever and chills :
Whether interior heat and exterior cold :
Sweating
Whether are sweating :
Where the sweating occurs :
Head
Whether headache :
Whether dizziness or vertigo :
Whether stiff neck and back :
Whether dry nose :
Whether nasal congestion :
Whether runny nose :
Whether the nasal discharge is clear or turbid :
Whether a sore under the nose :
Mouth
Whether bad taste in mouth :
Whether bad breath :
Whether toothache :
Thirst
Whether feel thirsty and dry in mouth :
Whether prefer cold or hot water :
Amount of water drank :
Nausea and vomiting
Whether dry heave :
Whether vomit :
Throat
Whether a sore throat :
Whether throat is dry :
Whether have ang foreign object in the throat :
Coughing
Whether are coughing :
Whether phlegm :
Whether the phlegm is clear or turbid :
Whether persistent asthma :
Deafness
Whether ear block :
Whether are deaf :
Whether tinnitus :
Body
Whether sores or rashes on the body :
Whether feel body pain :
Whether lower back pain :
Whether bone or joint pain :
Whether feel restless :
Whether yellowing skin :
Whether feel fullness or heaviness in the abdomen, and can not turn over easily :
Whether the mouth and face feel numb :
Whether have any body pain :
Heart and chest
Whether feel irritable :
Whether palpitations :
Whether feel fullness in the chest :
Whether feel rebellious qi in chest :
Whether feel anxiety experienced as a feeling of oppression in the heart :
Whether shortness of breath :
Whether a lack of qi :
Whether feel hardness under the chest :
Whether chest pain :
Whether feel pain under the chest :
Whether a hard lump under the chest :
Whether feel pain or whip-like pain under the chest :
Whether fullness under the chest without pain :
Whether feel nausia :
Whether a feverish sensation in the chest :
Whether a feeling of qi rushing up towards the heart :
Whether a burning or hot sensation in the middle of the heart :
Ribs
Whether feel rib pain :
Whether hardness of the rib area :
Whether water qi under the rib area :
Abdomen
Whether abdominal pain :
Whether abdominal mass :
Whether feel palpitation under the navel :
Whether feel urgent urge to defecate :
Whether a rumbling sound in the abdomen :
Back
Whether back pain :
Whether aversion to cold on the back :
Limbs
Whether cold hands and feet :
Whether difficulty stretching their limbs :
Whether leg cramps :
Whether feel heavy pain all over their limbs :
Urination
Whether difficulty urinating :
Whether frequent urination :
Whether urgency to urinate :
Whether involuntary urination :
Color of urine :
Volume of urine :
Bowel movements
Whether constipation :
Whether diarrhea :
Whether incomplete evacuation :
Whether the stool is sticky :
Whether pus or blood in the stool :
Diet
Whether acid regurgitation :
Whether feel stomach distention :
Whether vomit after eating :
Whether lack appetite :
Sleep
Whether difficulty sleeping, insomnia :
Whether are easily awakened :
Whether are sleepy :
Spirit
Whether are incoherent :
Whether feverish talk :
Whether are weary and drowsy :
Whether are irritable :
Medical history
Whether a medical history :
Cause
Whether know the cause of the illness :
Female menstruation
Whether menstrual time is normal or early or delayed or irregular :
Color of menstrual blood :
Whether blood clots :
Whether dysmenorrhea :
Whether other discomforts along with menstruation :
Whether vaginal discharge :
Color of vaginal discharge :
Whether the amount of vaginal discharge is large or small :
Whether an odor :
Whether breast hyperplasia :
Tongue color
Tongue color :
Facial color
Normal facial color :
Red facial color :
White facial color :
Blue facial color :
Black facial color :
Pulse
Floating pulse :
Tight pulse :
Strong and forceful pulse :
Deep pulse :
Slippery pulse :
Fine and weak pulse :
Work and rest
Sleep Time :
Wake up time :
routine work :
Other instructions :
Other remarks :
