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Traditional Chinese Medicine Questionnaire
1.) Energy level:
I am pale
I have a red flushed complexion
My chest has a red flush to it
I get headaches
3.) The climate seems to make my condition worse when:
Climate changes do not affect me
Step: 2 of 5
Trouble falling asleep
Trouble staying asleep
I wake in the middle of the night
I have vivid dreams
I sleep more than 10 hours a day
I take sleep medications
I feel anxiety when I try to sleep
5.) Subjective Body Temperature:
I have night sweats
I feel warm most of the day
I use multiple blankets when I sleep
I prefer to wear sweaters
Heat makes me feel tired
My hands and feet are always colder
than the rest of my body
I feel chilled most of the time
I prefer chilled beverages
I am hungry all the time
I have bleeding gums
I have bad breath
I am overweight
I am underweight
I prefer warm beverages
I don't have much of an appetite
When I wake up
Undigested food particles
Multiple movements throughout the day
Pain in the diaphragm area
Step: 3 of 5
Frequent daytime urination
Frequent nighttime urination
Clear profuse urination
Dark/ pungent smelling urination
Known Prostate problems
9.) Skin & Nails:
Dry/flaky finger nails
Fungus on toenails
Red/blood shot eyes
Itchy red eyes
Loosing eye sight
Chronic ear infections with smell
Sensitive to noise
Chronic ear infections without smell
Worse with inhalation
Worse with exhale
I have lots of phlegm
Nasal congestion without mucus
Nasal congestion with mucus
Nasal congestion that occurs seasonally
14.) What season worsens your condition?:
Step: 4 of 5
Lots of anger/short tempered
Withdrawn: prefer to be alone
I take anti-depressant medications
Tendons problems (tell the location below)
Doctor has said you have arthritis?
Doctor has said you have R.A.?
The type of pain can be described as:
Worse with movement
Better with movement
I have swelling around the joints
I have redness around the joints
Cold makes it worse
Heat makes it worse
Damp weather makes it worse
Do you have weakness of the lower back?
Do you have weakness of the knees?
When did the pain start?
Does anything make it better?
Does anything make it worse?
Step: 5 of 5 - Please tell us your information
What is your main compliant today?
How long has it been a problem?
List all medications and supplements you are taking:
List all herbs that you are taking?
What medical diagnoses have you received?
Review of systems:
Do you have high blood pressure?
Do you have any problems with your Heart?
Do you have problems with your Liver?
Do you have problems with your Kidneys?
Do you have neurological problems?
Please tell us your contact information
Retype Email Address:
Cell/Nightime Tel #:
Best Time to Call:
Prefer Phone call or Email:
Have you ever worked with herbs before?
Please tell us what questions or concerns you may have so that we may help you purchase one of our formulas:
What is your state? We would like to know where you are located to be able to call you at the right time:
If other please tell us where other is:
Final comments: Please tell us anything you feel that has not been asked:
How did you find us?
Other - Please tell us
If other please tell us who other is:
a place where Chinese herbal formulas are sold for just about anything your looking for. When buying herbs always remember that herbs do not cure diseases, however they do create immense customer satisfaction. Chinese herbs are used for what is known as patterns of disharmonies....there is a big difference between a pattern and a disease...
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