TCM Clinic

Traditional Chinese Medicine Initial Consultation Form

Consultation date:______________

Surname: __________________________ Name: ______________________________

Date of Birth: ___________________ Occupation: _____________________________

Alerts: O Diabetes O Methicillin-Resistant Staphylococcus Aureus

O Pulmonary Disease O Anti-Coagulant

O Allergy O Hepatitis O Birth-control

Brief Clinical Manifestations:

Presenting Chief Complaint: ________________________________________________
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Onset: _____________________________ Duration: ___________________________

Occurrence: _____________________________________________________________

Presenting signs and symptoms (related details concerning chief complaint):

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Systems Review (only where applicable to patient)

Appetite: ______________ Cravings: ________________ Taste: _________________

Abdominal bloating/pain: ___________________________________________________
Nausea/vomiting: _________________________________________________________
Bowels (frequency): _______________________________________________________
Stools (hard/soft/dry/colour): ________________________________________________
Urination (frequency/colour): _______________________________________________
Thirst: ___________________________ Water (Qty): ___________________________
Alcohol (Qty): ____________________ Caffeine (Qty): _________________________
Vision: __________________________ Hearing: ______________________________

SOB Dysponea/Asthma: _____________________________________ Smoker: Yes/No

Perspiration: _______________________ Chills/Fever: _________________________
Skin (dry/oily etc.): _______________________________________________________
Eczema: ____________________________ Psoriasis: ___________________________
Skin allergies: ____________________________________________________________

Sensitivity to climatic/temperature changes: ____________________________________

Musculoskeletal pain/numbness:
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Energy level 1 (low) – 10 (high) Morning: _____ Afternoon: ______ Evening: ______
Sleep (hours/night): ____________ Time sleeping and waking: ___________________
Emotions: _______________________________________________________________
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Palpitations: _____________________________________________________________
Menstruation:
First day of last period: __________________ Day in cycle: ______________________
History of menstruation:
Age of menarche: ___________________ Age of menopause: ____________________
Length of cycle: ________________
Number of days bleeding: ______________
Blood (colour/thickness): _________________
Clots: _________________________________
Any associated pain: _______________________________________________________
OCP: Yes/No
History of Childbirth: ______________________________________________________

Others
Medication/Supplements: ___________________________________________________
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Past illness/Accidents/Injuries/Allergies/Surgeries: ______________________________

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Family History: __________________________________________________________

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Exercise/Relaxation: _______________________________________________________
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TCM Observations:
Tongue:
Body: _____________________________ Coat: _______________________________
Pulse:
Left: ______________________________ Right: ______________________________

Summary of conditions (please provide a brief description as to why you made the diagnosis and treatment principle summing
up major symptoms)

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TCM Diagnosis
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Treatment Principle
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Acupuncture Prescription:
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Method of Manipulation:
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Herbal Prescription:
Formula Name: ________________________________
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Administration:
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Consulting Student:
Name (Printed): ___________________________ Signature: _____________________

Herb Dispensing Student:

Name (Printed): ___________________________ Signature: _____________________

Supervisor’s Signature: ______________________________ Date: ________________