TCM Online Consultation Form

Please fill in the consultation form below and send it to the email address [email protected]. We will arrange for a professional TCM practitioner to respond to your inquiry via email within 24 hours.
Part 1: Basic Information
Full Name:
_________________________
Country:
_________________________
Address:
_________________________
Phone Number:
_________________________
Email:
_________________________
Alternate Email or Contact:
_________________________
Age:
______ years
Gender:
□ Male □ Female □ Other
Height:
______ cm
Weight:
______ kg
Body temperature:
______ ℃
Heart rate:
______ bpm
Blood pressure:
______ mmHg
Occupation:
_________________________
Nature of Work:
□ Sedentary office □ Physical labor □ Standing work □ Frequent travel □ Home-based □ Other
Marital/Parental Status:
□ Single □ Married □ Trying to conceive □ Have children (___ children) □ Other
Living Environment:
□ Urban □ Suburban □ Rural □ Coastal □ Inland □ Other
Part 2: Chief Complaints & Health Goals
2.1 Main Health Concerns (Please rank in order of severity, 1 being most severe)
Concern 1:
Issue: _________________ Duration: ______ Severity (1-10): ___
Concern 2:
Issue: _________________ Duration: ______ Severity (1-10): ___
Concern 3:
Issue: _________________ Duration: ______ Severity (1-10): ___
Common Options:
□ Sleep issues □ Mood issues □ Digestive issues □ Fatigue □ Headache □ Menstrual issues □ Skin problems □ Weight issues □ Weak immunity □ Pain (neck/shoulder/back/joints) □ Other
Health Goals:
□ Complete symptom resolution □ Significant symptom improvement □ Improve constitution, prevent recurrence □ Health maintenance, anti-aging □ Other
Expected Duration of Care:
□ 1 month (short-term) □ 3 months (one constitutional adjustment cycle) □ 6 months (deep care) □ Long-term maintenance □ Unsure
Part 3: Temperature Sensation & Sweating
3.1 Temperature Sensation
Overall, do you feel more sensitive to cold or heat?
□ Sensitive to cold □ Sensitive to heat □ Both明顯 □ No obvious preference
Location of cold sensitivity:
□ Whole body □ Hands and feet □ Back □ Abdomen □ Knees □ Other
Degree of cold sensitivity:
□ Dress more than others □ Dress less than others □ Need extra heating □ Need long sleeves even in summer
Location of heat sensitivity:
□ Whole body □ Palms and soles □ Chest □ Head □ Other
Type of heat sensation:
□ None □ Afternoon tidal fever □ Five-palm heat (heat in palms, soles, chest) □ Paroxysmal flushing heat
Sensitive to AC/fans?
□ No discomfort □ Feel unwell when blown □ Must use □ Fear of wind
Hands and feet in winter:
□ Warm □ Cold (need hot water bottle/foot soak to warm) □ History of chilblains
Hands and feet in summer:
□ Normal □ Palms and soles feel hot □ Palms sweat
3.2 Sweating
Overall amount of sweat:
□ Normal □ Excessive □ Scant □ Almost no sweating
When do you tend to sweat easily?
□ Profuse sweating with slight movement □ Sweating while eating □ Night sweats □ Daytime sweating without reason □ Sweating when nervous
Location of sweat:
□ Whole body □ Head and face □ Palms and soles □ Back □ Chest □ Armpits
Nature of sweat:
□ Thin and watery □ Sticky □ Yellowish □ Foul-smelling
Feeling after sweating:
□ Comfortable □ Fear of wind/cold □ Fatigue □ No special feeling
Part 4: Head, Face & Mental State
4.1 Head
Do you have headaches?
□ No □ Yes
Location of headache:
□ Forehead □ Back of head □ Temples □ Top of head □ Whole head □ One side
Nature of headache:
□ Distending pain □ Stabbing pain □ Empty pain □ Heavy pain □ Dull pain □ Throbbing pain
Timing of headache:
□ Morning □ Afternoon □ Evening □ Irregular □ After exertion □ After emotional changes
Do you have dizziness?
□ No □ Yes
Nature of dizziness:
□ Sensation of spinning □ Feeling of floating/lightheadedness □ Blackout before eyes □ Heavy, groggy feeling
Timing of dizziness:
□ When getting up or lying down □ When standing up after sitting □ Persistent
4.2 Face & Senses
Facial complexion:
□ Rosy □ Pale □ Sallow □ Dark/Dull □ Flushed □ Bluish/Purple □ Normal
Eyes:
□ Normal □ Dry □ Blurred vision □ Excessive discharge □ Yellowish sclera □ Red sclera □ Dark circles □ Swollen eyelids
Nose:
□ Normal □ Stuffy nose □ Runny nose (□ Clear □ Yellow) □ Reduced sense of smell □ Dry nose □ Prone to nosebleeds
Mouth:
□ Normal □ Bitter taste □ Dry mouth □ Bad breath □ Sticky sensation in mouth □ Mouth ulcers □ Bleeding gums
Throat:
□ Normal □ Dry throat □ Sore throat □ Sensation of lump □ Hoarseness □ Prone to choking
4.3 Thirst & Drinking
Do you feel thirsty?
□ Not thirsty □ Thirsty, want to drink □ Thirsty but don't want to drink □ Dry mouth but not thirsty
Preferred drink temperature:
□ Ice water □ Cold water □ Warm water □ Hot water □ No preference
Amount of water consumed:
□ Normal □ More than average □ Less than average
Feeling after drinking water:
□ Quenches thirst □ Still thirsty □ Abdominal bloating □ Increased urination
4.4 Ears & Hearing
Is your hearing normal?
□ Normal □ Mildly reduced □ Significantly reduced □ Deafness
Do you have tinnitus?
□ No □ Yes (□ Cicada-like □ Buzzing □ Machinery-like □ Pulsing)
Pattern of tinnitus:
□ Constant □ Intermittent □ Worsens with fatigue
Do you have a feeling of fullness in the ears?
□ No □ Yes
4.5 Mental & Emotional State
Mental state:
□ Energetic □ Easily fatigued □ Sleepy □ Irritable □ Low mood □ Anxious □ Loss of interest □ Difficulty concentrating □ Forgetful
Characteristics of fatigue:
□ Energetic in morning, tired in afternoon □ Tired all day □ Worsens with activity □ Not relieved by rest
Other conditions:
□ Palpitations □ Chest tightness/shortness of breath □ Feeling of restlessness □ Timid, easily startled □ Sighing frequently
Memory:
□ Normal □ Reduced short-term memory □ Reduced long-term memory
Part 5: Sleep
Average bedtime:
______ : ______ (24h format)
How long does it take to fall asleep?
□ <20 min □ 20-40 min □ 40-60 min □ >60 min
Manifestation of difficulty falling asleep:
□ Can't stop racing thoughts □ Body restless, can't calm down □ No obvious reason
Number of night awakenings:
□ 0 times □ 1-2 times □ 3-4 times □ >4 times
Can you fall back asleep after waking?
□ Easily □ With difficulty □ Cannot fall back asleep
Do you have vivid dreams?
□ No □ Yes, occasionally □ Yes, frequently □ Many nightmares
Do you snore?
□ No □ Mild □ Severe □ Have apnea (wake up gasping)
Feeling upon waking:
□ Refreshed □ Still tired □ Groggy, heavy head □ Dry mouth, bitter taste □ Swollen eyelids
Daytime sleepiness level:
□ None □ Mild □ Moderate □ Severe (involuntary nodding off)
Average sleep duration:
Approximately ______ hours/day
Do you take naps?
□ Never □ Occasionally □ Frequently (______ minutes)
Do you take sleep aids?
□ No □ Western medicine (______) □ Chinese medicine/supplements (______)
Part 6: Appetite & Taste
Appetite:
□ Normal □ Increased appetite □ Poor appetite □ Full after a few bites □ Hungry but no desire to eat
Food quantity:
□ Normal □ More than average □ Less than average
Post-meal reaction:
□ No discomfort □ Bloating □ Belching □ Acid reflux □ Nausea □ Immediately sleepy □ Food regurgitation
Taste preferences:
□ Prefer hot drinks □ Prefer cold drinks □ Prefer sweet □ Prefer spicy □ Prefer salty □ Prefer sour □ Prefer greasy □ No clear preference
Craving for specific foods?
□ No □ Meat □ Sweets □ Fried food □ Raw/cold food □ Spicy food
Drinking habits:
□ Drink a lot □ Drink little □ Normal □ Only drink when thirsty
What do you prefer to drink?
□ Warm water □ Cold water □ Ice water □ Tea □ Soft drinks
Do you feel thirsty?
□ No □ Thirsty, want to drink □ Thirsty but don't want to drink □ Dry mouth but not thirsty
Do you have a bitter taste in the mouth?
□ No □ In the morning □ After meals □ All day
Do you have bad breath?
□ No □ Yes
Do you have acid reflux or heartburn?
□ No □ Occasionally □ Frequently
Part 7: Bowel & Bladder
7.1 Bowel Movements
Frequency:
□ Once daily □ 2-3 times daily □ Once every 2 days □ Once every 3+ days □ >3 times daily
Typical time:
□ Morning □ After meals □ Irregular
Form/Consistency:
□ Formed □ Hard, dry □ Soft, loose □ Hard first, loose later □ Watery □ Sticky (leaves residue)
Color:
□ Brownish-yellow □ Black □ Bloody □ Green □ Pale/clay-colored
Sensation:
□ Smooth □ Straining □ Sensation of incomplete evacuation □ Rectal heaviness
Do you have abdominal pain before a bowel movement?
□ No □ Yes
Do you take laxatives?
□ No □ Yes (______)
7.2 Urination
Color:
□ Pale yellow □ Dark yellow □ Clear like water □ Red □ Cloudy
Frequency:
□ Normal during day □ Frequent during day □ Nighttime urination (___ times/night)
Sensation:
□ Smooth □ Burning sensation □ Pain/Stinging □ Sensation of incomplete emptying □ Excessive foam
Do you have incontinence/leakage?
□ No □ Yes (when coughing/sneezing/jumping) □ Bedwetting
Part 8: Chest, Abdomen, Back & Limbs
8.1 Chest
Do you have chest tightness?
□ No □ Occasionally □ Frequently
Do you have chest pain?
□ No □ Yes (Location: □ Precordial □ Retrosternal □ Sides)
Do you have palpitations?
□ No □ Yes (Triggers: □ Exertion □ Emotions □ Fasting □ No trigger)
Do you have distending pain in the hypochondrium?
□ No □ Yes (□ Left □ Right □ Both sides, Related to emotions? □ Yes □ No)
8.2 Abdomen
Do you have abdominal bloating?
□ No □ After meals □ All day □ Relieved after passing gas
Do you have abdominal pain?
□ No □ Yes (Location: □ Epigastric □ Periumbilical □ Lower abdomen □ Whole abdomen; Nature: □ Dull □ Distending □ Stabbing □ Cold pain)
Does pressure on the abdomen feel good or bad?
□ Pressure feels good □ Pressure feels bad □ No special feeling
Does warmth or cold feel better on the abdomen?
□ Prefers warmth □ Prefers cool
Do you have any abdominal masses?
□ No □ Yes (______)
8.3 Back & Limbs
Do you have low back ache/pain?
□ No □ Yes (□ Ache □ Pain □ Cold □ Heaviness)
Characteristics of low back pain:
□ Worsens with fatigue □ Relieved by rest □ Worsens at night □ Relieved by activity
Do you have back pain (upper/mid)?
□ No □ Yes (Location: □ Upper back □ Lower back)
Sensations in limbs:
□ Normal □ Numbness □ Heaviness □ Aching □ Weakness
Joint condition:
□ Normal □ Pain (Location: ______) □ Swelling □ Limited range of motion
Do you have edema (swelling)?
□ No □ Yes (Location: □ Eyelids □ Hands □ Ankles □ Lower legs; Timing: □ Morning □ Afternoon □ All day)
Part 9: Women's Health (Optional)
Age of first menstruation:
______ years
Menstrual cycle:
□ Regular (___ days) □ Short (advances) □ Long (delayed) □ Completely irregular
Duration of period:
______ days
Flow volume:
□ Normal □ Heavy □ Light □ Prolonged spotting
Color of menstrual blood:
□ Bright red □ Dark red □ Pale red □ Deep brown/black
Consistency:
□ Normal □ Thin, watery □ Thick, sticky □ Many clots
Dysmenorrhea (painful periods):
□ No □ Yes (□ Before period □ During period □ After period; Severity: □ Mild □ Moderate □ Severe)
Premenstrual syndrome (PMS):
□ None □ Breast tenderness □ Mood swings □ Headache □ Edema □ Acne
Date of last menstrual period:
______ Year ______ Month ______ Day
Vaginal discharge amount:
□ Normal □ Increased □ Decreased
Color of discharge:
□ White □ Yellow □ Yellow-green □ Blood-tinged
Consistency of discharge:
□ Thin, clear □ Thick, sticky □ Cottage cheese-like □ Frothy
Odor of discharge:
□ None □ Fishy □ Foul
Are you pregnant/breastfeeding?
□ No □ Pregnant (___ weeks) □ Breastfeeding (___ months postpartum)
Are you perimenopausal?
□ No □ Yes
Gynecological history:
□ None □ Yes (______)
Women's Health - In-depth
Number of pregnancies:
______
Number of deliveries:
______ (Vaginal ______ Cesarean ______)
Number of miscarriages:
______ (Spontaneous ______ Induced ______)
Postpartum hemorrhage?
□ No □ Yes
Postpartum depression?
□ No □ Yes
Currently breastfeeding?
□ No □ Yes (______ months)
Breast condition after weaning:
□ Normal □ Loose/Relaxed □ Atrophied □ Nodules
Menopausal stage:
□ Not yet □ Perimenopausal □ Postmenopausal (______ years)
Menopausal symptoms:
□ Hot flashes □ Night sweats □ Insomnia □ Mood swings □ Vaginal dryness □ Decreased libido
Using hormone replacement therapy (HRT)?
□ No □ Yes
Part 10: Men's Health (Optional)
Do you have soreness/weakness in lower back and knees?
□ No □ Mild □ Moderate □ Severe
Do you have frequent nighttime urination?
□ 0 times □ 1 time □ 2 times □ 3+ times
Do you have decreased energy levels?
□ No □ Mild □ Moderate □ Severe
Changes in sexual function:
□ Normal □ Decreased □ Other (______)
Prostate issues:
□ None □ Frequent/urgent urination □ Difficulty urinating □ Perineal pain/distension
Men's Health - In-depth
Prostate history:
□ None □ Prostatitis □ Benign prostatic hyperplasia (BPH) □ Elevated PSA
Urinary symptoms:
□ Frequent urination □ Urgency □ Painful urination □ Weak stream □ Hesitancy □ Post-void dribbling
Sexual function:
□ Normal □ Decreased libido □ Erectile dysfunction □ Premature ejaculation □ Painful ejaculation
Semen condition:
Color: □ Grayish-white □ Yellow □ Blood-tinged; Volume: □ Normal □ Low
Testicular condition:
□ Normal □ History of undescended testicle □ Atrophy □ Nodules/Mass
Children's Health (Optional)
Feeding method (infants):
□ Breastfeeding □ Formula □ Mixed
Teething:
□ Normal □ Delayed (______ months)
Crying/startling during sleep?
□ No □ Yes
Night crying?
□ No □ Yes
Prone to colds/fever?
□ Rarely □ Occasionally □ Frequently
Part 11: Tongue Diagnosis (Please take a photo)
📌 Photo guide: Take in natural light, no filters, open mouth and stick out tongue to show entire surface. Best taken in the morning on an empty stomach, before brushing teeth.
Tongue body color:
□ Pale red □ Pale white □ Red □ Crimson □ Purple-dark □ Blue-purple
Tongue coating thickness:
□ Thin □ Thick
Tongue coating color:
□ White □ White and greasy □ Yellow □ Yellow and greasy □ Gray-black □ No coating
Tongue coating moisture:
□ Moist □ Dry □ Slippery □ Greasy □ Rotten □ Peeling (geographic)
Tongue body shape:
□ Normal □ Swollen/Fatty □ Thin/Emaciated □ Teeth marks □ Cracks □ Prickles □ Deviated □ Trembling
Sublingual veins:
□ Not prominent □ Visible □ Dilated/tortuous/bluish-purple
Other descriptions:
_________________________
Photo of tongue surface:
[Photo area]
Photo of sublingual veins:
[Photo area]
Part 12: Medical History & Medications
12.1 Past Medical History
□ None
□ Hypertension (______ years, Control: □ Good □ Fair □ Poor)
□ Diabetes (______ years, Control: □ Good □ Fair □ Poor)
□ High cholesterol □ Heart disease □ Liver disease □ Kidney disease □ Thyroid disease □ Gout □ Anemia
□ Stomach disease (□ Gastritis □ Ulcer □ GERD)
□ Anxiety/Depression (□ Diagnosed □ Currently treating)
□ Tumor (______) □ Surgery history (______) □ Injury history (______)
□ Allergies (□ Medication □ Food □ Pollen □ Other: ______)
12.2 Current Medications
Medication name:
_________________ Dosage: ______ Duration: ______ Reason: ______
Medication name:
_________________ Dosage: ______ Duration: ______ Reason: ______
12.3 Supplements/Chinese Herbs
Name:
_________________ Dosage: ______ Duration: ______
Part 13: Lifestyle Habits
13.1 Smoking & Alcohol
Smoking:
□ Never □ Occasionally □ Regularly (______ cigarettes/day, ______ years)
Alcohol:
□ Never □ Occasionally (______ times/month) □ Regularly (______ times/week)
13.2 Exercise
Frequency:
□ Almost never □ 1-2 times/week □ 3-5 times/week □ Daily
Type:
□ Walking □ Running □ Swimming □ Yoga □ Gym workouts □ Ball sports □ Baduanjin/Tai Chi □ Other
Duration per session:
______ minutes
Intensity:
□ Light □ Moderate □ Vigorous
13.3 Work & Stress
Working hours:
Average ______ hours/day
Stress self-rating (1-10):
______
Main sources of stress:
□ Work □ Family □ Finances □ Health □ Relationships □ Other
Stress coping methods:
□ Talk it out □ Exercise □ Eat □ Shop □ Drink alcohol □ Smoke □ Keep it inside
13.4 Other
Do you often stay up late?
□ Never □ Occasionally □ Frequently
Do you often travel/jet lag?
□ No □ Yes (Frequency: ______ times/month)
Exposure to hazardous materials?
□ No □ Yes (______)
Part 15: Additional Information
Please describe any symptoms, special circumstances, or questions not covered:
_________________________________________________________________________________
_________________________________________________________________________________
Part 16: Pulse Diagnosis (Only for in-person consultations, to be filled by TCM practitioner. If not available, can be filled for reference)
Pulse PositionLeft HandRight Hand
Cun (Heart/Lung)Pulse depth: □ Superficial □ Middle □ Deep　Rate: □ Slow □ Moderate □ Rapid □ Very rapid　Strength: □ Strong □ Weak　Shape: □ Large □ Thin □ Wiry □ Slippery □ Choppy □ Tense □ Soft □ WeakSame as left
Guan (Liver/Spleen)Same as aboveSame as above
Chi (Kidney/Kidney)Same as aboveSame as above
Overall pulse interpretation:
_________________________________
Part 17: Auscultation & Olfaction (Sound & Smell)
17.1 Voice Characteristics
Voice volume:
□ Normal □ Loud and strong □ Low and weak □ Variable
Speech rate:
□ Normal □ Fast □ Slow □ Variable
Voice quality:
□ Clear □ Hoarse □ Muffled □ Sharp □ Dull
Breath support for speech:
□ Adequate □ Short of breath □ Weak voice
Cough sound:
□ None □ Dry cough □ Deep, muffled cough □ Weak, low cough
Breath sounds:
□ Smooth □ Rough □ Faint □ Wheezing
Bowel sounds:
□ Normal □ Active □ Hyperactive □ Diminished
Hiccups/Belching:
□ None □ Occasionally □ Frequent (□ Odorless □ Sour/putrid)
17.2 Odor Characteristics
Breath odor:
□ None □ Present (□ Sour/putrid □ Foul □ Fruity/acetone)
Body odor (sweat):
□ Odorless □ Sour □ Fishy □ Foul
General body odor:
□ No special odor □ Unusual odor
Stool odor:
□ No special odor □ Foul □ Sour
Urine odor:
□ No special odor □ Ammonia-like □ Sweet/fruity
Part 18: Hand & Ear Examination (Optional)
18.1 Hand Diagnosis
Palm color:
□ Rosy □ Pale □ Dark red □ Yellowish □ Bluish □ Purplish
Palm temperature:
□ Warm □ Cold □ Hot (bothersome heat)
Palm moisture:
□ Dry □ Moist □ Sweaty
Nail shape:
□ Smooth and shiny □ Vertical ridges □ Horizontal ridges □ Pitted □ Brittle/cracked □ Thickened
Nail color:
□ Pink □ Pale □ Purplish □ Yellowish □ Black lines
Lunulae (half-moons):
□ 8-10 on both hands □ Fewer than normal □ Overly large □ Bluish
Thenar eminence:
□ Full/Plump □ Flat □ Bluish
Hypothenar eminence:
□ Normal □ Red
18.2 Ear Diagnosis
Ear auricle color:
□ Rosy □ Pale □ Red □ Bluish □ Blackish
Ear luster:
□ Shiny □ Dull
Ear elasticity:
□ Soft and elastic □ Stiff □ Too soft
Earlobe:
□ Full/Plump □ Shriveled □ Crease/line
Tender points on ear acupoints:
□ None □ Yes (Location: ______)
Part 19: Inspection (Optional)
21.1 Observation of Spirit (Shen)
Eye expression:
□ Bright and spirited □ Dull, vacant gaze □ Wandering gaze □ Drooping eyelids
Facial complexion:
□ Rosy and lustrous □ Pale □ Sallow □ Dark/Dull □ Flushed □ Bluish-purple □ Blackish
Mental awareness:
□ Clear □ Lethargic/Sleepy □ Clouded □ Irritable/Restless □ Delirious □ Unconscious
Reaction speed:
□ Quick □ Sluggish □ Apathetic
21.2 Observation of Body Shape
Overall body type:
□ Well-proportioned □ Obese (□ Evenly distributed □ Abdominal obesity) □ Thin □ Muscular
Bone structure:
□ Large/sturdy □ Medium □ Small/delicate
Muscle fullness:
□ Full and strong □ Soft and weak □ Thin, little muscle
Fat distribution:
□ Even □ Mainly abdominal □ Mainly limbs □ Thickened back
21.3 Observation of Posture/Movement
Sitting posture:
□ Upright □ Curled up □ Restless/fidgety □ Prefers lying on back □ Prefers lying on stomach
Gait:
□ Normal □ Limping □ Dragging leg □ Shuffling/hurried □ Unsteady/drunken
Movements:
□ Agile □ Sluggish □ Tremors □ Twitching/Spasms □ Numbness, lack of sensation
21.4 Observation of Skin
Skin color:
□ Normal □ Pale □ Yellowish □ Reddish □ Bluish □ Purplish □ Blackish
Skin moisture/texture:
□ Moist/Lustrous □ Dry □ Oily □ Flaking/Scaling
Rash/Spots:
□ None □ Yes (Location: ______ Appearance: ______)
Hair:
□ Normal □ Thin/Sparse □ Dry/Brittle □ Prematurely gray □ Hair loss
Varicose veins:
□ None □ Yes (Location: ______)
Part 20: Inspection of Excretions (Sputum, Nasal Discharge, Vomit, Stool/Urine Appearance)
Do you cough up phlegm/sputum?
□ No □ Yes (□ White □ Yellow □ Yellow-green □ Blood-tinged; □ Thin □ Thick/sticky)
Do you have nasal discharge?
□ No □ Yes (□ Thin and clear □ White and thick □ Yellow and thick □ Blood-tinged)
Vomit (if any):
□ None □ Clear, watery □ Food residue □ Yellow-green □ Coffee-ground □ Bright red blood
Undigested food in stool?
□ No □ Yes
Mucus/pus/blood in stool?
□ None □ Mucus □ Pus/Blood □ Bright red blood
Is urine cloudy?
□ Clear □ Cloudy
Foam in urine?
□ None □ A little □ A lot
Part 21: Meridian Diagnosis
Urinary Bladder Meridian (back):
□ Normal □ Muscle stiffness □ Ropey nodules □ Tenderness □ Soft, sunken muscles
Stomach Meridian (face, lower limbs):
□ Normal □ Facial pigmentation □ Cold/pain in lower limbs
Liver Meridian (inner thighs, hypochondrium):
□ Normal □ Tenderness □ Tension
Conception Vessel (Ren Mai) (midline of chest/abdomen):
□ Normal □ Tenderness □ Tension □ Sunken
Governing Vessel (Du Mai) (midline of back):
□ Normal □ Tenderness □ Scoliosis □ Stiffness
Part 22: Environmental & Social Factors
Climate of residence:
□ Cold and dry □ Cold and humid □ Hot and dry □ Hot and humid □ Four distinct seasons
Residence floor level:
□ 1-3 □ 4-6 □ 7+ □ Basement
Home ventilation:
□ Good □ Fair □ Poor
Work environment:
□ Office □ Factory □ Outdoor □ Kitchen □ Hospital □ Other______
Prolonged exposure to AC environment:
□ Yes (______ hours/day) □ No
Prolonged exposure to chemicals:
□ No □ Yes
Social support:
□ Adequate □ Fair □ Lacking
Financial stress:
□ None □ Mild □ Moderate □ Severe
Life satisfaction (1-10):
______
Part 23: Dynamic Diagnosis (Time Dimension)
When did the current discomfort begin?
Specific date/time: ______
Was there a trigger for the onset?
□ Cold exposure □ Heat exposure □ Dietary irregularity □ Overwork □ Emotional stress □ Injury
How have symptoms changed over time?
□ Gradually worsening □ Gradually improving □ Fluctuating □ No significant change
Relationship with seasons?
□ Worse in spring □ Worse in summer □ Worse in late summer □ Worse in autumn □ Worse in winter □ No relation
Relationship with weather?
□ Worse on rainy/cloudy days □ Worse on dry days □ Worse on cold days □ No relation
Relationship with time of day?
□ Worse in early morning □ Worse in late morning □ Worse in afternoon □ Worse in evening □ Worse at night
Relationship with meals?
□ Worse before meals □ Worse after meals □ Worse when hungry □ No relation
Relationship with emotions?
□ Worse when angry □ Worse when stressed □ Worse when sad □ No relation
Have you had similar symptoms before?
□ First time □ Have had before
Previous treatments and effects?
Treatment: ______ Effect: □ Resolved □ Improved □ No effect
Part 24: Previous Treatment Response History
Treatment TypeHave you tried?Effect (+++ Great / ++ Moderate / + Slight / 0 None / - Worse)
Chinese herbal decoction□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Patent Chinese medicine□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Acupuncture□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Moxibustion□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Tui Na / Massage□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Cupping / Scraping (Gua Sha)□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Western medicine□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Dietary therapy□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Exercise therapy□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Psychological / Meditation□ Yes □ No□ +++ □ ++ □ + □ 0 □ -
Have you experienced symptoms worsening after treatment?
□ No □ Yes (______)
Part 25: Treatment Goals & Adherence Assessment
What is your expectation for this treatment?
□ Complete symptom resolution □ Significant improvement □ Mild improvement □ Just trying it out
How much time can you commit to treatment daily?
□ <10 min □ 10-20 min □ 20-40 min □ 40-60 min □ >60 min
How willing are you to change lifestyle habits?
□ Very willing □ Willing □ Neutral □ Not very willing □ Unwilling
What is your past success rate with sticking to health plans?
□ High (>80%) □ Moderate (50-80%) □ Low (<50%) □ Never tried
Main barriers to adherence?
□ Lack of time □ Lack of motivation □ Forgetfulness □ Too much trouble □ Unclear effects □ Other
Do you need regular reminders/check-ins?
□ Yes (□ Daily □ Weekly) □ No
Part 26: TCM Health Risk Assessment (Red Flag Screening)

⚠️ The following are "Red Flags". If you have any, please seek immediate in-person medical care:

□ Unexplained significant weight loss (>5% in 3 months)

□ Persistent fever (>38.5°C for over 3 days)

□ Night sweats with weight loss

□ Coughing up blood / Blood in stool / Black tarry stool

□ Chest pain radiating to left arm/jaw

□ Sudden severe headache ("thunderclap")

□ Unilateral limb weakness/numbness/drooping mouth corner

□ Difficulty breathing / Wheezing

□ Altered consciousness / Fainting

□ Suicidal thoughts (with a clear plan)

□ Pregnancy (especially first 3 months or last 3 months with complications)

□ Active malignant tumor

□ Severe liver or kidney dysfunction

Do you have any of the above?
□ No □ Yes (Please specify item number: ______)
If you have any of the above, this treatment plan is only for auxiliary reference. Please prioritize in-person medical care.
Part 27: Informed Consent & Authorization
□ I have filled out all information truthfully and have not concealed anything.
□ I understand that TCM diagnosis is not a substitute for emergency medical care, and I will seek immediate in-person care for any red flag symptoms.
□ I consent to the practitioner performing TCM pattern differentiation and formulating a health plan based on my information.
□ I consent to the practitioner contacting me if necessary for additional information.
Regarding confidentiality of my health information:
□ Strictly confidential □ Allow anonymous use for academic cases □ Allow practitioner to discuss (anonymously) in professional supervision
□ I understand that treatment is a process and typically takes 3 months or more to see significant results.
□ I agree to complete symptom scoring before treatment begins, every 4 weeks, and at the end of treatment to track progress.
Signature: _________________________
Date: ______ Year ______ Month ______ Day
Part 28: Diagnosis Validity Confirmation
Date this form was completed:
______ Year ______ Month ______ Day
The health status reflected in this form represents the past:
______ weeks
Has your health status changed significantly in the past 2 weeks?
□ No □ Yes (______)
Validity of this diagnosis:
□ Valid for 1 month □ Valid for 3 months (if no major changes)
Part 29: Service Boundaries & Disclaimer
1. What this service does NOT replace
□ Does not replace emergency medical care (e.g., heart attack, stroke, trauma)
□ Does not replace specialist diagnosis (e.g., cancer diagnosis, surgical evaluation)
□ Does not replace psychiatric emergencies (e.g., severe suicide risk)
2. Limitations of this service
□ Online diagnosis cannot perform pulse taking, primarily relies on tongue and inquiry diagnosis
□ Remote assessment has limitations; regular in-person check-ups are recommended
□ Herbal recommendations in the plan are for reference regarding treatment direction; please consult a local TCM practitioner for specific medication use
3. Client Responsibilities
□ Provide truthful information; concealing important medical history may affect plan safety
□ Seek medical attention if new symptoms appear or existing symptoms worsen
□ Take ultimate responsibility for personal health decisions
4. Our Responsibilities
□ Provide individualized treatment recommendations based on professional TCM theory
□ Protect client privacy, do not disclose information without authorization
□ Take responsibility for the professionalism of the plan
I have read and understood the above:
□ Yes □ No

Comprehensive TCM Health Plan · Customized Diagnosis Document | Version V1.0 |

This service is for TCM health maintenance and does not replace emergency medical care. In case of emergency, please go to the nearest medical facility immediately.