Date: |
|
Name: |
First name: |
Address: |
Date of birth: |
Chief complaint: ............................................................................................ |
Health insurance: ............................................................................................ |
Surgery or Hospitalization: ............................................................................................ |
Medications and dietary supplements: ............................................................................................ |
Medical History: ............................................................................................ |
Appetite: ............................................................................................ |
Thirst: ............................................................................................ |
Bowel Movement: ............................................................................................ |
Urination: ............................................................................................ |
Perspiration: ............................................................................................ |
Menstruation: ............................................................................................ |
Respiration: ............................................................................................ |
Zang-Fu organs: ............................................................................................ |
Vitality: ............................................................................................ |
Sleep: ............................................................................................ |
Climatic sensations: ............................................................................................ |
Sense organs: ............................................................................................ |
Pain (Localization and quality): ............................................................................................ |
Pulse: ............................................................................................ |
Tongue: ............................................................................................ |