TCM Health Consultation Questionnaire Health Evaluation Questionnaire 1. Do you feel any pains around the body? If so, please provide the details. No, I don't have any pains Yes, my pain details are 2. How is your diet, appetite, and feeling? Do you prefer hot or cold foods/drinks? Do you vomit? Please provide as much detail as possible (same as below). My appetite is normal, I don't feel any discomforts related to diet. I have the following diet symptoms 3. How is your stool? Do you have constipation, hiarrhoea? No, my stool is normal. Yes, I have the following stool symptoms 4. How is your urine? Do you feel pain urinating? What is the color and amount of the urine? My urines are normal with clear color and proper amount. I have the following urine symptoms 5. Do you often feel thirsty? If so, do you desire to drink? No, I don't feel thirsty. Yes, my thirst details are 6. How is your energy level? Do you often feel tired? No, I don't feel tired. Yes, my tiredness details are 7. Do you have headache, dizzines, facial pain, bleeding gums, or mouth ulcers? No, I don't have any of the above symptoms. Yes, my symptoms in the head are 8. Do you have pain in the whole body, joints, back, or numbness? No I have the following symptoms 9. Do you feel anything wrong in the area between the chest and abdomen? No, I feel fine in this area. Yes, I have the following symptoms in this area 10. Do you feel any discomfort in the limbs? No Yes, I have the following symptoms in the limbs 11. Do you have insomnia or feel lethargy? No Yes, I have the following sleeping symptoms 12. Do you sweat excessively? * Yes No 13. Do you suffer from tinnitus or loss of hearing? No Yes, I have the following symptoms in the ear 14. Do you have eye pain, blurred vision or dry eyes? No Yes, I have the following symptoms in the eyes 15. Do you feel cold, heat or fever? No Yes, the detais of my feeling are 16. Do you have any emotional symptoms? * Depression Fear/anxiety Irritability/anger Worry/overthinking Sadness and grief No, I don't have any of the above symptoms 17. Do you have any sexual symptoms? * Lack of libido Impotence (Men only) Premature ejaculation (Men only) Tiredness and dizziness after ejaculation (Men only) Headache soon after orgasm (Women only) No, I don't have any of the above symptoms 18. (Women Only) Do you have any symptoms related to the following area? * Menstruation Leucorrhoea Pregnancy Childbirth No 19. (Children Only) Do you have any symptoms related to the following area? * Digestive symptoms Respiratory symptoms and earache Sleep Immunizations No My other symptoms are: Name (First, Last) * Phone # Email * Note If you are human, leave this field blank. Submit