Complete Individual Health Report

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This is the most important health report form for you from the viewpoints of traditional Chinese medicine. Please read carefully and tick off the items correctly, so that our professional doctors could diagnose accurately and offer effective treatment for you.

The reason why you have to fill out this form seriously is that TCM is totally different than western medicine, and it emphasizes every exact individual symptom very much. Even for the same disease, there are many different reasons to cause it from person to person. Therefore the treatment is also different from person to person. Thanks for your understanding and cooperation.

Your email:  

Name:

Gender: male or female 

Marriage state: married or unmarried 

Having a child or children: already or not yet 

Age: years

Country:

Height:  meters

Weight:   kilograms

Disease history: how many years

What about your major complaints at present? Do you have the health problems of the heart and blood pressure? Serious or slight?   

Detailed Symptoms About You:

    headache

    great loss of hair

    slight loss of hair

    hair loss with oily scalp

    blurred vision

    blood-shot eyes

    dizziness

    tinnitus with noise of chirping of a cicada

    reduced hearing ability

    pale complexion

    swollen and painful nose

    runny nose

    thin and white nasal discharge

    thick and yellowish discharge

    blockaded sense in the nose

    a bitter taste in the mouth

    sour taste in the mouth

    dry lips

    slightly reddish tongue body

    slightly whitish tongue body

    deep-red tongue body

    fissured tongue body

    tooth-marks on the edges of the tongue

    I brush the tongue coating daily

    thick tongue coating

    thin tongue coating

    thin and white tongue coating

    thick and white tongue coating

    thin and yellow tongue coating

    thick and yellowish tongue coating

    stiff neck

    painful neck

    itching throat

    dry throat

    swollen and painful throat

    frequent throat inflammation

    spit thin and white phlegm

    spit thick and yellowish phlegm

    chest oppression

    shortness of breath

    slightly difficult breathing 

    middle degree difficulty in breathing  

    severe difficulty in breathing  

    slight palpitations

    severe palpitations

    stabbing pains in the heart

    distention and discomfort of the right rib-side

    having slight heart problem  

    having middle degree problem of the heart  

    having severe heart problem  

    having slight problem of the blood pressure  

    having middle degree problem of the blood pressure  

    having severe problem of the blood pressure  

    stomach pains

    stomach distention

    burning stomachache

    cold stomachache

    shrinking sense of the stomach

    stomachache likes warmth or warm drinks

    stomachache likes pressure on it

    wish to vomit

    dropping sense of the stomach

    belch with sour taste in the mouth

    lower abdomen pains

    lower abdomen distention

    lower abdominal pains like warmth and pressure

    painful back with inability or difficulty to stretch or bend the back

    aching pains of the shoulders and back

    stiff and painful loins due to falling or sprain or hard physical work

    dull pains of the loins

    left kidney area pains

    right kidney area pains

    cold sense on the back

    stiff four limbs

    general body pains

    muscle spasm of the body

    tight or spasmodic tendons of the general body

    running pains of the body joints

    heavy sense wrapping the body

    swollen and painful joints of the arms

    swollen and painful joints of the legs

    edema of the lower limbs

    edema of the general body

    numbness of the four limbs

    aversion to cold and cold limbs

    hot sense in the soles and palms in the afternoon or night often

    day time sweat

    sweat at night

    insomnia

    dreaminess

    frequent waking up during sleep

    thirst and like drinks

    like cold drinks

    like hot drinks

    reduced appetite

    easy hunger and excessive food-intake

    hunger without desire to eat

    eat much cold foods

    eat much fast foods

    irregular food intake

    frequent daytime urination

    urgency in urination

    white urine

    yellowish urine

    dark yellow urine

    painful urination

    frequent night urination

    dribbling urine after urination

    constipation

    diarrhea with burning sense at the anus

    diarrhea with clear undigested foods

    diarrhea worsened by emotional frustration or distress

    diarrhea every 5 O'clock (AM) with abdominal pains

Thanks so much for your patience that you are still working carefully on this form.

If you are a male, please thick off here:

    reduced sexual ability

    impotence

    premature ejaculation

    weak erection

    seminal emission in the daytime

    seminal emission at night

    reduced desire of sex

    frequent masturbation one to two years

    frequent masturbation two to four years

    frequent masturbation more than four years

    testicle pains one side

    testicle pains two sides

    swollen scrotum

    cold damp scrotum

    itching scrotum

    damp heat scrotum

    private part with strong smell

    pains of the perineum

    burning sense in the urethra

    excretion from the opening of the urethra

    dropping sense of the anus

    too strong sexual desire

    sterility

If you a female, please tick off here:

    reduced sexual desire

    irregular menstruation

    advanced menstruation

    delayed menstruation

    painful menstruation

    too much amount of menstrual blood

    too little amount of menstrual blood

    burning sense in the womb

    the womb like warmth and pressure

    cold sense in the womb

    thin color of the menstrual blood

    deep red color of the menstrual blood

    purplish color of the menstrual blood

    menstrual blood clots

    profuse and sudden uterine bleeding

    gradual uterine bleeding

    amenorrhea (stop of menstruation)

    profuse and thin leucorrhoea 

    profuse, thick and yellow leucorrhoea

    infertility

    strong sexual desire

Wrist Pulse:

    powerful pulse

    weak pulse

    50 to 60 wrist beats per minute

    60 to 80 wrist beats per minute

    80 to 100 wrist beats per minute

    100 to 120 wrist beats per minute

    thin pulse body like a thread

    deep pulse

    string-like pulse (touching the wrist pulse like touching a tight string of a musical instrument)

    abnormal rhythm of pulse

Living Environment:

    always a cold and windy living environment

    damp living environment

    dry living environment

Temperament and Emotions:

    optimistic, open-minded and happy

    pessimistic

    melancholic

    always worrisome

    nervous often

    overthinking often

    lone and close-minded

    easy to be angry always

  depressed often

   irritability often

Spirit and work:

    fatigued

    stressful work

    too much stressful work

What kind of  foods do you like? What are your daily foods? Do you smoke? What are your private hobby? Do your family members suffer the similar health problems?

If you have some clinical laboratory examinations, please offer the results. Also you could fax the documents of your laboratory check to our 86 745 2813349. Thanks.

What about current or past prescribed medications, and their effects? Any past hospitalizations for this or other diseases? Do you suffer from other internal diseases? If you do, please describe the degree of seriousness. 

Before submitting your form, please check if you have correctly filled out your email address. Thanks.

If you can't submit your form, please copy your form and send it to our email tcmtreatment@tcmtreatment.com or tcmtreatment@tcmtreatment.net . Thanks!