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: __________________________________________________________________________________________________________________________________________________________________________________________________________
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