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TCM Diagnosis Inquiry
About
TCM Diagnosis Inquiry
Traditional Chinese Medicine Questionnaire
Please answer the following questions according to your actual situation.
Gender
Male
Female
Email
Reason for visit
Inquiry Sleep
What time do you sleep at night
Sleep status
Good,Sleep through the night.
Hard to fallasleep
Easily fall asleep but wake up easily
Intermittent sleep, restless sleep
Wake up often at 1:00~3:00 in the mid-night
Wake up often from 3:00 to 5:00 in the mid-night
Dreamful
Night sweats
Feeling hot when falling asleep
Feeling cold when falling asleep.
Feeling sluggish when waking up in the morning, as if don’t get enough sleep
Always want to sleep during the day
Supplemental description
Appetite
Normal,feeling hungry when it's time to eat, appetitive.
Not hungry when it's time to eat, not very appetitive
Need to eat immediately when hungry. If not, will feelPalpitation.
No taste when eating
Huge appetite
Poor appetite
Nausea
Vomiting
Sour regurgitation
Stomachache
Bloating
Belching
Gas rushes upwards
Supplemental description
Bowel Movement
Once a day
Several times a day
Once every 2~3 days
Once more than 4 days
Need to use drugs to make a bowel movement
Forming Stool
Yellow
Green
Black
Dry Stool and hard to make a bowel movement
Pelletized like sheep shit
Not formingstool
Slimy and sticky
Watery
Smelly
Not smelly
Blood after stool
Blood before stool
Blood and stool mixed
Too much fart
Don't fart
Diarrhea and anal pain
Supplemental description
Urination
About 4~5 times a day
Fewer times, less urine
Urinating dripping like water from a tap
Urgency
Drinking a glass of water and peeing a glass
Get up in the mid-night to urinate
Cannot urinate
Nocturnal enuresis
Enuresis during the day (can't hold back urine)
Astheniaof urination
Red pain in urination
Light yellow in color
Clear in color
Yellow in color
Dark yellow in color
Brown, brown in color
Hematuria
Bubbly in urine, not easy to disperse
Turbid in color
Supplemental description
Thirst condition
Have a normal desire to drink water
Not thirsty, do not want to drink water
Dry mouth and thirsty, while do not want to drink water
Very thirsty and need to drink a lot of water
Dry throat
Tongue feels dry
Dry lips
Like to drink warm water and hot water
Like to drink cold water, ice water
Feels dry and bitter in the mouth when gets up in the morning
Bad breath
Feel sweet in the mouth
Vomit after drinking water
Too much saliva, always spitting
Supplemental description
Cold and heat conditions
Hands and feet are warm in four seasons
Hands and feet are cold in four seasons
Hands and feet are warm in summer, coldin winter
Palms are very hot
Hands and feet to arms and calves are cold
Arch of feet are very hot
Body feels cold
Intolerance of cold
Feeling cold on the back
Fever
Intolerance of cold and heat now and then
Supplemental description
Sweating situation
Sweat normally, only when doing sport or labouring or the weather is hot and muggy
Sweat not easily
Sweat a lot, sweating even if you move a little
Sweating on the left side of the body
Sweating on the right side of the body
Night sweats
Sweat easily on palms and soles
Sweat only on the head, no sweat below the neck
Supplemental description
Chest and abdomen conditions
Dysphoria
Palpitation, faster heartbeat
Shortness of breath, difficulty to inhale
Shortness of breath, difficult to exhale
Feeling gas rushing upwards
Chest tightness, fullness
Fullness of the chest and hypochondrium
Stomach bloating, above the belly button
Abdominal bloating, below the belly button
Abdominal pain
Supplemental description
Cough, wheezing, phlegmsituation
Non-productive cough without sputum
With phlegm but not coughing
Cough
Asthma
White phlegm
Phlegm is like rice porridge
The sputum is foamy
Yellow sputum
Sputum is easy to expel
Sputum is not easy to expel
Tickly throat
Sore throat
Bloods in sputum
coarse breathing with rale
Without the above symptoms
Energy and physical status
Good spirit
Good energy
Feeling drowsy
Weak,lacking of energy
Feeling the body is heavy especially while walking, feeling fatigue
Supplemental description
Women's menstruation
Normal menstruation, 28 days
Early menstruation
Delayed menstruation
Normal color, bright red
Light color
Crimson color
Has blood clots
Dysmenorrhea
Unpleasant smell
Supplemental description
Emotional situation
Dysphoria
Dysphoria at night, unable to sleep
Get angry easily
Crazy, insanity
Speak nonsense
Talking to oneself, chattering endlessly
Melancholy
Sorrow
Sad and tearful for no reason
None of the above
Supplemental description
Whether there is pain and paralysis
Whether there is a skin disease and abscess
The Man Problem
Premature ejaculation
nocturnal emission
Penis pain
Impotence
Has morning wood
No morning wood
Supplemental description
Have you had any treatment before, and have you had any surgery?
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