TCM Clinic

Traditional Chinese Medicine Follow-Up Consultation Form

Consultation date:______________

Surname: __________________________ Name: ______________________________

Presenting Chief Complaint (Progress from previous treatment):

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Questions about Relevant Health Conditions:

Appetite/Cravings: ________________ Bloating/Pain/Indigestion: _________________

Nausea: _____________ Thirst: _______________ Water (Qty): _________________
Perspiration: ________________________ Urination: ___________________________
Bowels (frequency): _________________ Stools (formation): _____________________
Energy Level 1 (low) – 10 (high) Morning: ______ Afternoon: ______ Evening: _______
Sleep (hours/night): _________ Time sleeping and waking: ________ Dreams: Yes/No
Wake feeling refreshed: ___________ Emotions: _______________________________
Pain: ___________________________________________________________________
Menstruation: ____________ Day in cycle: ____________ Length: _______________
Blood (colour/thickness): __________________ Regularity: ______________________
Any associated pain: _______________________________________________________
Others: _________________________________________________________________
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Tongue:
Body: _________________________ Coat: ___________________________________

Pulse:
Left: _____________________________ Right: _______________________________

TCM Diagnosis:
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Treatment Principle
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Acupuncture Prescription:
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Herbal Prescription:
Formula Name: __________________________________
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Consulting Student:
Name (Printed): ___________________________________ Signature: _____________________________

Herb Dispensing Student:

Name (Printed): ___________________________________ Signature:______________________________

Supervisor’s Signature: ___________________________________ Date: ___________________________