FAMILY HEALTH HOLISTIC CENTER

In-Depth Health Questionnaire from the Perspective of Traditional Chinese Medicine (TCM)
To be completed before your initial consultation

Para este formulario en Español, oprima aqui.

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For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

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What is your main concern for this consultation? How long do you have it?

Have you seen a physician for the condition? What is the diagnosis?

What medicine or treatment has your physician prescribed for the condition? How long have you used? How well do you respond to it?

Have you seen a Chinese herbal doctor or an acupuncturist for the condition? What is the diagnosis or prescription?

Have you taken any herbal remedy for the condition? What are they, the dosage, and for how long? How did you respond to them?

Do you have any of the following if they are not the main concern above?
Diabetes: yes no do no know. If yes, the blood sugar level:
High Cholesterol: yes no do no know. If yes, the total cholesterol level:
High Pressure: yes no do no know. If yes, the blood pressure level:
Stroke: yes no. If yes, when did it happen last time:
Heart Disease: yes no do no know. If yes, when did it happen last time:
Kidney Disease: yes no do no know. If yes, Specify:
Liver Disease: yes no do no know. If yes, Specify:

Any other major medical condition do you have? yes no do no know. If yes, Specify:

Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Fever: yes no.
Persistent low fever: yes no.
Heat intolerance: yes no.
Cold limbs: yes no.
Cold fingers/feet: yes no.
Cold back: yes no.
Chilly sensation: yes no.
Warm and moist palms/sole: yes no.
Warm and moist skin: yes no.
Spontaneous perspiration: yes no.
Night sweat: yes no.

Pale face: yes no.
Flushed face: yes no.
Fatigue: yes no.
Lassitude: yes no.
Weak voice: yes no.
Lack of interest in talking: yes no.
Short of breath: yes no.
Weak pulse: yes no.

Headaches: yes no.
Migraine headaches (one side): yes no.
Tension headaches: yes no.
Cluster headaches: yes no.
Dizziness: yes no.
Spinning: yes no.
Tinnitus (ring in the ears): yes no.
Blurred vision: yes no.
Red eye: yes no.
Eye pain: yes no.
Hair loss: yes no.
Hair graying: yes no.

Sore throat: yes no.
Difficult chewing or swallowing: yes no.
Dry mouth: yes no.
Thirst with desire for drinking: yes no.
Thirst without desire for drinking: yes no.
Bitter mouth: yes no.
Mouth odor: yes no.
Noticed difference in tongue color and coating from others: yes no.

Runny Nose: yes no.
Stuffy Nose: yes no.
Cough: yes no.
Cough with little phlegm: yes no.
Cough with water phlegm: yes no.
Cough with yellow phlegm: yes no.
Cough with bloody phlegm: yes no.
Dry cough: yes no.
Wheezing: yes no.
Asthma: yes no.

Chest pain: yes no.
Abdominal pain: yes no.
Abdominal pain, relief with pressure: yes no.
Abdominal pain, worse with pressure: yes no.
Flank pain: yes no.
Shoulder pain: yes no.
Low back pain: yes no.
Low back weakness: yes no.
Arm pain: yes no.
Leg pain: yes no.
Arm/leg weakness: yes no.
Extremity numbness: yes no.
Leg pain while walking: yes no.
Joint pain: yes no.
Joint swelling: yes no.

Forgetfulness: yes no.
Emotional stress: yes no.
Mood swings: yes no.
Restlessness: yes no.
Depression: yes no.
Anxiety: yes no.
Irritability: yes no.
Mania: yes no.
Sleepiness: yes no.
Difficulty falling asleep: yes no.
Difficulty staying asleep: yes no.
Frequent awakenings: yes no.
Insomnia: yes no.
Dreamfulness: yes no.
Palpitation: yes no.
Angina: yes no.

Recent weight gain: yes no.
Recent weight loss: yes no.
Edema: yes no.
Poor appetite: yes no.
Nausea: yes no.
Vomiting: yes no.
Bloating: yes no.
Abdominal distention: yes no.
Indigestion: yes no.
Heartburn: yes no.
Stomachache: yes no.
Change in bowl habits: yes no.
Dry stool: yes no.
Loose stool: yes no.
Bloody stool: yes no.
Diarrhea: yes no.
Constipation: yes no.
Anal burning: yesno.

Frequent urination: yes no.
Urinary urgency: yes no.
Urinary pain: yes no.
Urinary dripping: yes no.
Urinary difficulty: yes no.

Women only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Pain in menstruation: yes no.
Menstruation disorders: yes no.
Menstruation irregularity: yes no.
Bleeding between periods: yes no.
Bleeding after menopause: yes no.
Hot flash: yes no.
Breast distention: yes no.
In pregnancy: yes no.
In lactation: yes no.

Men only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Premature ejaculation: yes no.
Weak erection: yes no.
Impotence: yes no.
Excessive sexual drive: yes no.
Loss of sexual drive: yes no.
Emission: yes no.
Active sexual life: yes no. How often:
Masturbation: yes no. How often:

Please scroll up to the top and double check what you have completed and correct any error before submission