CHINESE MEDICINE ASSESSMENT FORM

CLIENT INTAKE FORM 

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PATIENT INFORMATION FORM

 

Part A: Please check any symptoms that apply to you now or in the last 3 months.

Part B: Please check any symptoms that apply to you now or in the last 3 months.

Part C:

Part D. (Women Only):

Part E: (Men & Women)

Part F: (Last 3 months)

Part G: (Last 3 months)

Part H: (medication)

Part I: (Alternative Medicine)

Part J: (Check if you have ever had)

Part K: Do You Eat, Drink or Use

 

PART L: Family History of: (list who in your family)

 

TYPICAL DIET

Please provide what a typical day would like. Record all the foods you eat and drink. Be sure to include the approximate amount of each food. The herbalist will provide a food therapy report if this section is incomplete. Your diet is key to better health.

 

CONSITITUTION ASSESSMENT FORM

 Directions:

0 point for no condition exists (0 events per month)
1 point for mild symptoms (1-2 events per month)
2 points for moderate symptoms (3-6 events per month)
3 points for a severe condition (7 events+ per month)
If a condition doesn’t apply then leave the item blank.

Men and women: Fill out both Yin and Yang sections below.

For unclear items, consult your Traditional Chinese Medicine practitioner.

 

YIN CONSTITUTION

 

YIN: COLD CONSTITUTION

 

YIN: DAMP CONSTITUTION

 

YIN: DEFICIENT CONSTITUTION

 

YANG CONSTITUTION

*Men and women: Fill out both Yin and Yang sections.

 

YANG: HOT CONSTITUTION

 

YANG: DRY CONSTITUTION

 

YANG: EXCESSIVE CONSTITUTION

 

Final Questions

 

Emotion

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