TCM Questionnaire - Ameling Chiropractic & Acupuncture



TCM Questionnaire

Patient_____________________Age_____Height_______Weight________Date______

Instructions: Circle the number that applies to you. If a symptom does not apply, leave it blank.

Circle either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occurs several times a month), or (3) of SEVERE symptoms (occurs almost constantly).

Throat

-----------------------

Appetite and Digestion

1- 1 2 3 Good Appetite 12- 1 2 3 Bloating 23- 1 2 3 Crave salty flavors

2- 1 2 3 Poor Appetite 13- 1 2 3 Heartburn 24- 1 2 3 Crave sour flavors

3- 1 2 3 Excessive Appetite 14- 1 2 3 Food Stagnation 25- 1 2 3 Crave bitter flavors

4- 1 2 3 Constant Appetite 15- 1 2 3 Have regular meals 26- 1 2 3 Crave sweet flavors

5- 1 2 3 Rapid Hungering 16- 1 2 3 Have sour regurgitation 27- 1 2 3 Crave spicy flavors

6- 1 2 3 Anorexia 17- 1 2 3 Taste your food 28- 1 2 3 Avoid salty flavors

7- 1 2 3 Hungry, but no 18- 1 2 3 Have ‘noisy’ stomach 29- 1 2 3 Avoid sour flavors

desire to eat 19- 1 2 3 Have indigestion 30- 1 2 3 Avoid bitter flavors

8- 1 2 3 Nausea 20- 1 2 3 Stomach pain or cramping 31- 1 2 3 Avoid sweet flavors

9- 1 2 3 Belching 21- 1 2 3 Bad breath 32- 1 2 3 Avoid spicy flavors

10- 1 2 3 Flatulence 22- 1 2 3 Get tired after meals

11- 1 2 3 Vomiting

Describe: _____________________________________________________________________________________________

Drinking

1- 1 2 3 Have thirst w/out desire to drink 4- 1 2 3 Dry mouth

2- 1 2 3 Not thirsty but drink a lot of water anyway 5- 1 2 3 Drink a lot

3- 1 2 3 Thirsty 6- 1 2 3 Drinking does not satisfy

Describe:_____________________________________________________________________________________________

Sensitivity and Allergy

1- 1 2 3 Cold 4- 1 2 3 Light 7- 1 2 3 Food

2- 1 2 3 Hot 5- 1 2 3 Airborne particles 8- 1 2 3 Drugs

3- 1 2 3 Dampness 6- 1 2 3 Noise 9- 1 2 3 Other_______________

Describe_____________________________________________________________________________________________

Perspiration

1- 1 2 3 Perspire when you should 5- 1 2 3 Do not perspire 8- 1 2 3 Night sweats

2- 1 2 3 Perspire on slight exertion 6- 1 2 3 Perspire too little 9- 1 2 3 Foul perspiration odor

3- 1 2 3 Perspire for no apparent reason 7- 1 2 3 Cold sweats 10- 1 2 3 Other______________

4- 1 2 3 Perspire profusely

Describe: ___________________________________________________________________________________________

Sleep Pattern

1- 1 2 3 Insomnia 8- 1 2 3 Deep sleeper 15- 1 2 3 Grinding teeth

2- 1 2 3 Get second wind at night 9- 1 2 3 Light sleeper 16- 1 2 3 Talking in sleep

3- 1 2 3 Difficult falling asleep 10- 1 2 3 Sleep shallowly awaken easily 17- 1 2 3 Feel wired & tired

4- 1 2 3 Take naps 11- 1 2 3 Bad sleep quality 18- 1 2 3 Difficulty awakening in

5- 1 2 3 Sleepy/ tired in daytime 12- 1 2 3 Many dreams the morning

6- 1 2 3 Snoring 13- 1 2 3 Bad dreams or nightmares 19- 1 2 3 Waking up at night

7- 1 2 3 Sleep apnea 14- 1 2 3 Wake too early What time?____________

Times per night? _______

Describe: ___________________________________________________________________________________________

Eyes

1- 1 2 3 Changes in vision 4- 1 2 3 Red eyes 7- 1 2 3 Watery eyes

2- 1 2 3 Blurry vision 5- 1 2 3 Dry eyes 8- 1 2 3 Itchy eyes

3- 1 2 3 Poor night vision 6- 1 2 3 Gritty eyes 9- 1 2 3 See floaters

Describe____________________________________________________________________________________

Ears

1- 1 2 3 Difficulty hearing 4- 1 2 3 Pressure in ears 6- 1 2 3 Low pitch ringing in ears

2- 1 2 3 Ear pain 5- 1 2 3 High pitch ringing in ears How long?___________

3- 1 2 3 Discharge from ears How long?____________

Describe: _____________________________________________________________________________________________

Nose

1- 1 2 3 Sinus Congestion 4- 1 2 3 Sinus infections 6- 1 2 3 Dry nose

2- 1 2 3 Sinus pain 5- 1 2 3 Nosebleeds 7- 1 2 3 Nose obstructed

3- 1 2 3 Constricted nasal passages

Describe: _____________________________________________________________________________________________

Mouth

1- 1 2 3 Tongue ulcers 4- 1 2 3 Bitter taste in mouth 6- 1 2 3 Tooth pain

2- 1 2 3 Bleeding gums 5- 1 2 3 Sour regurgitation 7- 1 2 3 Condition of teeth

3- 1 2 3 Other taste in mouth_________________

Describe: _____________________________________________________________________________________________

Respiration

1- 1 2 3 Difficulty inhaling 3- 1 2 3 Shortness of breath 5- 1 2 3 Shortness of breath

2- 1 2 3 Difficulty exhaling 4- 1 2 3 Shortness of breath on worse on lying down

slight exertion

Describe: _____________________________________________________________________________________________

Throat

1- 1 2 3 Sore throat 3- 1 2 3 Feeling of something in throat

2- 1 2 3 Difficulty swallowing 4- 1 2 3 Phlegm in throat

Describe: _____________________________________________________________________________________________

Muscles

1- 1 2 3 Muscle weakness 3- 1 2 3 Muscle aches 5- 1 2 3 Muscle tics

2- 1 2 3 Muscle Tension 4- 1 2 3 Muscle cramps 6- 1 2 3 Muscle spasms

Describe: _____________________________________________________________________________________________

Headaches

1- 1 2 3 Top of head 4- 1 2 3 Occiput (back of head) 7- 1 2 3 Starts in neck

2- 1 2 3 Forehead 5- 1 2 3 Sinuses 8- When?_____________________

3- 1 2 3 Temples 6- 1 2 3 In eyeballs

Describe: _____________________________________________________________________________________________

Pain

1- 1 2 3 Rapid onset 5- 1 2 3 Sharp pain 9- 1 2 3 Chest pain

2- 1 2 3 Gradual onset 6- 1 2 3 Low back pain 10- Fixed location ______________

3- 1 2 3 Burning pain 7- 1 2 3 Joint pain 11- Shifting locations____________

4- 1 2 3 Dull pain 8- 1 2 3 Under the ribs

Describe:______________________________________________________________________________________________

Coughs

1- 1 2 3 Dry 5- 1 2 3 Bloody 8- 1 2 3 Copious sputum

2- 1 2 3 Wet 6- 1 2 3 Clear sputum 9- 1 2 3 Small amts. of sputum

3- 1 2 3 Hacking 7- 1 2 3 Colored sputum 10- 1 2 3 Difficulty expelling

4- 1 2 3 Unproductive mucus/ phlegm

Describe: _____________________________________________________________________________________________

Energy

1- 1 2 3 Abundant 3- 1 2 3 Up and down 5- 1 2 3 Nervous energy

2- 1 2 3 Low 4- 1 2 3 Exhausted 6- 1 2 3 Hyperactive

Energy Level- 1 2 3 4 5 6 7 8 9 10

(1 Low – 10 High)

Describe: _____________________________________________________________________________________________

Temperature

1- 1 2 3 Tend to be cold/ cool 8- 1 2 3 Tend to hot/ warm 15- 1 2 3 Have heat/ warmth in

2- 1 2 3 Cold hands 9- 1 2 3 Hot flash palms or soles

3- 1 2 3 Have chilly arms 10- 1 2 3 Sensitive to weather changes 16- 1 2 3 Have heat/ warmth in

4- 1 2 3 Cold feet 11- 1 2 3 Have low grade fever all the time lower back

5- 1 2 3 Have chilly legs 12- 1 2 3 Have recurrent fevers 17- 1 2 3 Have deep heat in body

6- 1 2 3 Have recurrent chills 13- 1 2 3 Feel warmer in afternoon/ evening 18- 1 2 3 Have cold in lower back

7- 1 2 3 Alternating hot & cold 14- 1 2 3 Prefer hot/ warm drinks 19- 1 2 3 Prefer cold/ cool drinks

What is opinion regarding your body temperature? ____________________________________________________________

What season of the year do you prefer and why? ______________________________________________________________

Bowel Movement

1- 1 2 3 Constipation 6- 1 2 3 Incomplete 11- 1 2 3 Soft stools

2- 1 2 3 Diarrhea 7- 1 2 3 Hard stools 12- 1 2 3 Undigested foods

3- 1 2 3 Cramping 8- 1 2 3 Strong smell 13- 1 2 3 With blood

4- 1 2 3 Loose 9- 1 2 3 With mucous

5- 1 2 3 Watery 10- 1 2 3 “Coffee ground” appearance 14- Color of stool?______________

How many a day?_____________ Time of day?______________________ Does it vary?___________________

Describe: _____________________________________________________________________________________________

Body Weight

1- Yes No Normal 3- Yes No Underweight 5- Yes No On weight control diet

2- Yes No Overweight 4- Yes No Medications lead to weight gain?

If overweight….

How many pounds would you like to loose? ____________________

How many year ago did you begin gaining weight? ______________

Emotions

1- 1 2 3 Depression 5- 1 2 3 Worry 9- 1 2 3 Weepy

2- 1 2 3 Sadness 6- 1 2 3 Overly excited 10- 1 2 3 Can’t stop thinking

3- 1 2 3 Fear 7- 1 2 3 Angry 11- 1 2 3 Anxiety

4- 1 2 3 Sensitive 8- 1 2 3 Anxiety

Have you recently had exceptionally stressful experiences? YES NO

Describe:___________________________________________________________________________________________________________________________________________________________________________________________________

Reproduction

Male & Female Female Male

1- 1 2 3 Low sexual energy 1- Pregnant now? Yes No 1- 1 2 3 Premature ejaculation

2- 1 2 3 Excessive sexual energy 2- Number of pregnancies? __________ 2- 1 2 3 Seminal emission

3- 1 2 3 Pain during sex 3- Number of children born? _________ 3- 1 2 3 Impotence

4- 1 2 3 Pain in genitals 4- Number of miscarriages? __________

5- 1 2 3 Itching in genitals 5- Number of abortions? _____________

6- 1 2 3 Discharge from genitals 6- Use of birth control? Yes No

Describe: _____________________ If yes, what type? ________________

_____________________________ How long? ______________________

_____________________________ 7- Yes No Are far as you know are you able to conceive?

_____________________________ 8- If unable to conceive, what do you believe the cause

to be? _______________________________

Describe:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Menstrual Cycle

1- Yes No Regular 9- Yes No Pain in back 17- Yes No Emotional changes before flow

2- Yes No Irregular 10- Yes No Pain in breast 18- Yes No Emotional changes after flow

3- Yes No Clots 11- Yes No Menses pale red color 19- Yes No Emotional changes during flow

4- Yes No Cramps 12- Yes No Menses dark red color 20- Yes No Depression around time of flow

5- Yes No Pain before flow 13- Yes No Menses bright red color 21- Yes No Irritability around time of flow 6- Yes No Pain during flow 14- Yes No Menses purplish color 22- Yes No Anger around time of flow

7- Yes No Pain after flow 15- Yes No Normal emotions during menses 23- Yes No Sadness around time of flow

8- Yes No Pain in abdomen 16- Yes No Emotional changes during menses 24- Yes No Crying around time of flow

Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Miscellaneous

1- 1 2 3 Poor memory 6- 1 2 3 Brittle nails 10- 1 2 3 Feeling of heaviness in body

2- 1 2 3 Mental restlessness 7- 1 2 3 Rashes 11- 1 2 3 Feeling of heaviness in head

3- 1 2 3 Feel own heart beat 8- 1 2 3 Itching 12- 1 2 3 Feeling of heaviness in limbs

4- 1 2 3 Dizziness 9- 1 2 3 Edema/ swelling

5- 1 2 3 Difficulty concentrating Where?______________

Please list any additional concerns you wish to address: __________________________________________________________________________________________________________________________________________________________________________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download