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:
............................................................................................

............................................................................................