7TCM Online TCM Consultation

Physical Condition:

Nature of Work:

Marital & Parental Status:

Living Environment:

2.1 Disease Course & Main Health Concerns (Please rank by severity, 1 being the most severe)

Common Options for Reference:

Regimen Goals:

Expected Regimen Duration:

3.1 Cold/Heat Sensation

Overall, do you feel more sensitive to cold or heat?

Areas sensitive to cold:

Degree of cold sensitivity:

Areas sensitive to heat:

Type of heat sensation:

Sensitive to air conditioning/fans?

Hands and feet in winter:

Hands and feet in summer:

3.2 Sweating

Overall sweat volume:

When do you sweat easily?

Sweating areas:

Sweat characteristics:

Feeling after sweating:

4.1 Head

Do you have headaches?

Headache location:

Headache nature:

Headache timing:

Do you have dizziness?

Dizziness nature:

Dizziness timing:

4.3 Thirst & Drinking

Do you feel thirsty?

Preferred drink temperature:

Daily water intake?

Feeling after drinking water:

4.4 Ears & Hearing

Is your hearing normal?

Do you have tinnitus?

Tinnitus sound:

Tinnitus persistence?

Do you have a feeling of fullness in the ears?

4.5 Spirit & Mentation

Mental state:

Characteristics of fatigue:

Other conditions:

Memory:

Average bedtime:

How long does it take to fall asleep?

Characteristics of difficulty falling asleep:

Number of nighttime awakenings:

Can you fall back asleep after waking?

Do you have vivid dreams?

Do you snore?

Morning feeling upon waking:

Level of daytime sleepiness:

Average sleep duration:

Do you take naps?

Do you take sleep aids?

Appetite:

Food intake:

Post-meal reactions:

Food preferences:

Do you crave specific foods?

Drinking habits:

Preferred beverages:

Do you feel thirsty?

Do you have a bitter taste in mouth?

Do you have bad breath?

Do you have acid reflux or heartburn?

7.1 Bowel Movement (Stool)

Frequency:

Typical time:

Stool consistency:

Stool color:

Sensations during defecation:

Do you experience abdominal pain before diarrhea?

Do you use laxatives?

7.2 Urination

Urine color:

Urination frequency:

Sensations during urination:

Do you have urinary incontinence/enuresis?

8.1 Chest

Do you have chest tightness?

Do you have chest pain?

Location of chest pain:

Do you have palpitations?

Triggers for palpitations:

Do you have hypochondriac pain/distension?

Location of hypochondriac pain:

Is it related to emotions?

8.2 Abdomen

Do you have abdominal bloating?

Do you have abdominal pain?

Location of abdominal pain:

Nature of abdominal pain:

Is abdominal pain relieved or worsened by pressure?

Does the abdomen prefer warmth or coolness?

Do you feel any abdominal masses?

8.3 Back and Limbs

Do you have lower back soreness or pain?

Nature of lower back soreness/pain:

Characteristics of lower back pain:

Do you have upper back pain?

Location of back pain:

Sensations in limbs:

Joint condition:

Do you have edema (swelling)?

Location of edema:

Timing of edema:

Menstrual cycle:

Menstrual flow volume:

Menstrual blood color:

Menstrual blood consistency:

Dysmenorrhea (painful periods):

Premenstrual syndrome (PMS):

Vaginal discharge (Leukorrhea) volume:

Vaginal discharge color:

Vaginal discharge consistency:

Vaginal discharge odor:

Are you pregnant or breastfeeding?

Are you perimenopausal?

Female In-depth Supplement

Postpartum hemorrhage?

Postpartum depression?

Breast condition after weaning:

Menopausal stage:

Menopausal symptoms:

Do you use Hormone Replacement Therapy (HRT)?

Do you have soreness and weakness in lower back and knees?

Do you have frequent night urination?

Do you have decreased energy?

Changes in sexual function:

Prostate issues:

Male In-depth Supplement

Prostate examination history:

Urinary symptoms:

Sexual function:

Semen color:

Semen volume:

Testicular condition:

Infant feeding method:

Teething status:

Crying or startling during sleep?

Does the child have night crying?

Does the child get colds/fever easily?

12.1 Past Medical History

Past medical history:

Hypertension:

Blood pressure control:

Diabetes:

Diabetes control:

Other conditions:

Stomach conditions:

Mood-related:

Tumor/Cancer:

Surgery history:

Injury/Trauma history:

Allergy history:

12.2 Current Medications

Medication 1:

Medication 2:

12.3 Supplements/Chinese Herbs

Supplements/Chinese Herbs:

13.1 Smoking & Alcohol

13.2 Exercise

13.3 Work & Stress

13.4 Other

Tongue body color:

Tongue coating thickness:

Tongue coating color:

Tongue coating moisture:

Tongue body shape:

Sublingual veins:

Other description:

Tongue surface photo:

Sublingual vein photo:

Abdominal Palpation Examination

Overall abdominal shape:

Area of abdominal distension:

Abdominal wall tension:

Tenderness and rebound tenderness:

Abdominal mass:

Temperature on abdominal palpation:

Palpable pulsations:

Bowel sounds:

Signs of ascites (fluid):

Other abdominal findings:

Position	Left Hand		Right Hand
Cun (Heart/Lung)	Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin		Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin
Guan (Liver/Spleen)	Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin		Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin
Chi (Kidney/Kidney)	Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin		Superficial Middle Deep Slow Moderate Rapid Very Rapid Forceful Weak Large Thin Wir/Tense Slippery Choppy/Rough Tight Soft/Floating-weak Weak/Deep-thin

Overall pulse pattern assessment:

17.1 Voice Characteristics

17.2 Odor Characteristics

18.1 Hand Diagnosis

18.2 Ear Diagnosis

19.1 Inspection of Spirit (Shen)

Eye expression:

Facial complexion:

Mental awareness:

Reaction speed:

19.2 Inspection of Body Shape

Overall body type:

Skeletal frame:

Muscle mass:

Fat distribution:

19.3 Inspection of Posture & Gait

Sitting posture:

Walking gait:

Movements:

19.4 Inspection of Skin

Skin color:

Skin moisture/texture:

Rash/Skin lesions:

Location of rash:

Morphology of rash:

Hair condition:

Varicose veins:

Location of varicose veins:

Do you cough up phlegm/sputum?

Sputum color:

Sputum consistency:

Do you have a runny nose?

Nasal discharge characteristics:

Vomitus (if applicable):

Undigested food in stool?

Mucus or blood in stool?

Is your urine cloudy?

Does your urine have foam?

Urinary Bladder Meridian (back):

Stomach Meridian (face, lower limbs):

Liver Meridian (inner thighs, hypochondrium):

Conception Vessel (Ren Mai - midline front):

Governing Vessel (Du Mai - midline back):

Treatment Modality	Tried?	Effect (+++ Excellent / ++ Good / + Slight / 0 None / - Worse)
Chinese Herbal Decoction	Yes No	+++ ++ + 0 -
Patent Chinese Medicine	Yes No	+++ ++ + 0 -
Acupuncture	Yes No	+++ ++ + 0 -
Moxibustion	Yes No	+++ ++ + 0 -
Tuina/Massage	Yes No	+++ ++ + 0 -
Cupping/Gua Sha	Yes No	+++ ++ + 0 -
Western Medicine	Yes No	+++ ++ + 0 -
Dietary Therapy	Yes No	+++ ++ + 0 -
Exercise Therapy	Yes No	+++ ++ + 0 -
Psychological/Mindfulness	Yes No	+++ ++ + 0 -

• I confirm that I have filled out all the above information truthfully and have not withheld any information.
• I understand that TCM diagnosis does not replace emergency or critical medical care. If I experience any red alert symptoms, I will seek in-person medical attention promptly.
• I consent to the practitioner performing TCM pattern differentiation and developing a health plan based on my information.
• I consent to the practitioner contacting me if necessary for additional information.

Confidentiality of my health information:

• Strictly confidential
• Allowed to be used anonymously for academic case studies
• Allowed to be discussed (anonymously) in practitioner professional supervision

• I understand that health conditioning is a process, and it typically takes over 3 months to see significant results.
• I agree to complete symptom quantitative assessments before starting, every 4 weeks, and at the end of the regimen to track effectiveness.

Signature:

Date:

Date this questionnaire was completed:

Time period this questionnaire reflects:

Have there been any major changes to your health status in the past 2 weeks?

Validity period of this diagnosis:

1. What this service does NOT replace

• Does not replace emergency or critical medical care (e.g., heart attack, stroke, trauma)
• Does not replace specialized diagnosis (e.g., cancer confirmation, surgical evaluation)
• Does not replace psychiatric emergency care (e.g., severe suicide risk)

2. Limitations of this service

• Online diagnosis cannot perform pulse taking; relies mainly on tongue inspection and inquiry.
• Remote assessment has inherent limitations; regular in-person physical examinations are recommended.
• Herbal recommendations in the plan are for reference as conditioning directions; consult a local TCM practitioner for specific medication.

3. Client responsibility

• Provide truthful and complete information; withholding significant medical history may affect plan safety.
• Seek medical attention promptly if new symptoms appear or existing symptoms worsen.
• Assume ultimate responsibility for personal health decisions.

4. Our responsibility

• Provide personalized conditioning recommendations based on professional TCM theory.
• Protect client privacy and not disclose information without authorization.
• Be responsible for the professionalism of the plan.