Professional Documents
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Health List
Health List
Choose the correct symptoms for yourself. The most urgent health problems need to be solved at present, such as high blood pressure, diabetes, migraine etc. Name: Gender: Age: Weight : Height:
Medical history: What diseases have you had before? When? What treatment did you take? How about the effects?
1. How would you describe your body type? Tall Medium height Short Lean Medium Burly Overweight Underweight
Yes
No
2. Have no appetite? Yes No 3. Eat at regular times? Yes No 4. Snack between meals? Yes No 5. Get hungry quickly after eating and want to eat more? Yes No 6. Get hungry, but have no desire to eat? Yes No 7. Have addiction to certain foods? No Yes Which foods 8. Do you feel dry in your mouth? Yes No 9. Do you feel bitter in your mouth? Yes No 10 What kind of predominant flavor do you like? Neutral Sweet Sour Bitter Pungent ( spicy ) Salty astringent 11. How about your digestion? Good 12. Do you have nausea? Yes No Just So So Bad
3. Drink
1. Are you thirsty often? Yes No 2. Never thirsty? Yes No 3. Feel better after drinking? Yes No 4. What drinks do you like? Hot drinks
Cold drinks
4. Sleep
1. Do you suffer from insomnia? Yes No Yes No 2. Is your sleeping light or deep? Light Deep 3. Is your sleep easily disturbed, either by outside influences or dreams or other? 4. Once awake, is it hard to go back to sleep? Yes No Yes No
5. If you wake up during the night regularly, does this happen on a particular time? 6. Do you suffer from drowsiness, or feeling sleepy during the day? Yes No
5. Perspiration
1. Do you easily sweat? Yes No 2. Feel cold while sweating? Yes No 3. Feel hot while sweating? Yes No 4. Will Sweat cause stain in the clothes Yes No 5. If so, what color of the stain: Yellow Red Black 6. If sweating is in a certain body location, please indicate: Head Torso chest back Palms Soles of feet Other:
Other color
6. Temperature
1. Do you often feel hot? Yes No 2. When do you feel hot? in the morning in the afternoon in the evening
3. Do you generally feel cold? Yes No 4. Do you strongly feel cold or slightly feel cold? 5. Are cold hands and feet a common occurrence?
7. Urine
1. How would you describe your urine? Clear color Light yellow Dark yellow 2. What is the odor of the urine? Strong odor 3. Time of urination: Long Short 4. Do you have retention of urine regularly? Yes 5. Night urination or not? No Yes 6. If yes, how many times about the night urination? 6. Any other comments: Blood in urine Muddy urine. Light odor No odor No times per night
8. bowels
1. How about your defecation? How many times per day or how many days for one time? Your answer:
2. How about your description of the bowels? (Choose the following answers fit for you) Loose bowels 3. Is there any undigested food in stool Yes 4. Is defecation painful? Yes No 5. Constipation? Yes No 6. Any other comments: No Dry and hard Water like Blood in bowels Black bloody bowels thick bloody
A. dull pain B. stabbing pain C. distending pain 11. How about the leucorrhea? A. Profuse leucorrhea with white color, thin texture and odorless B. leucorrhea with yellow color; sticky texture and foul C. leucorrhea with red color like mixed blood D. leucorrhea reddish or whitish 12. Do you have lumbago during the menstruation? If yes, how do you describe it? Yes No
4. Are your eye sockets sunken? Yes 5. Is the area around the eyes dark? Yes 6. Are your face and eyes dropsy? Yes
No No No
No Yes No
ache and weak in waist and knee, waist and leg. Bulge and tired, tremble, lump part
rigidity and vertical in waist, slowness in bend spread, ache in ponderosity in two legs, turgescence in foots and legs, two hands