TCM Health Consultation Questionnaire

Health Evaluation Questionnaire
1. Do you feel any pains around the body? If so, please provide the details.
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).
3. How is your stool? Do you have constipation, hiarrhoea?
4. How is your urine? Do you feel pain urinating? What is the color and amount of the urine?
5. Do you often feel thirsty? If so, do you desire to drink?
6. How is your energy level? Do you often feel tired?
7. Do you have headache, dizzines, facial pain, bleeding gums, or mouth ulcers?
8. Do you have pain in the whole body, joints, back, or numbness?
9. Do you feel anything wrong in the area between the chest and abdomen?
10. Do you feel any discomfort in the limbs?
11. Do you have insomnia or feel lethargy?
12. Do you sweat excessively? *
13. Do you suffer from tinnitus or loss of hearing?
14. Do you have eye pain, blurred vision or dry eyes?
15. Do you feel cold, heat or fever?
16. Do you have any emotional symptoms? *
17. Do you have any sexual symptoms? *
18. (Women Only) Do you have any symptoms related to the following area? *
19. (Children Only) Do you have any symptoms related to the following area? *