• TCM Client Health Condition Intake Form

    Share your basic details, main concerns, symptom patterns, and relevant medical and lifestyle history for your TCM intake review.

  • Part 1 Basic Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Format: (000) 000-0000.

  • Part 2 Main Concern & Health Goal

  • Part 3 Core Symptom Screening

  • Hot/Cold Sensation*
  • Sweating*
  • Headache*
  • Body Aches / Stiffness / Heavy Sensation*
  • Sleep*
  • Thirst & Drink Preference*
  • Appetite*
  • Abdominal Feeling
  • Stool*
  • Urine*
  • Chest, Throat & Respiration
  • Cough Type

  • Part 4 Medical & Medication History

  • Part 5 Lifestyle

  • Diet Preference
  • Stress Level
  • Exercise Frequency

  • Part 6 For Female Clients (Optional)

  • Menstrual cycle status
  • Pain during period

  • Part 7 Additional information

    Anything else you consider relevant for your health conditioning analysis

  • Disclaimer:

    This intake form is used for theoretical discussion based on the medical experience of Traditional Chinese Medicine. No herbal formulas will be provided. This cannot replace hospital diagnosis and treatment. All analysis is for reference only. If you are experiencing a medical emergency, please contact your local emergency services immediately.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: