Holistic Healthcare Organization
Traditional Chinese Medicine Intake Form
Constitution Assessment for Herbal Medicine
Section 1 – Personal Information
Full Name
Date of Birth
Location of Birth
Age
Gender
Nationality
Occupation
Phone Number
WhatsApp Number
Emergency Contact
Height
Weight
Section 2 – Main Reason for Consultation
What would you like help with?
☐ General Wellness
☐ Immune Support
☐ Detoxification
☐ Cancer Prevention / Health Optimization
☐ Stress
☐ Anxiety
☐ Sleep
☐ Digestive Health
☐ Fatigue
☐ Hormonal Balance
☐ Chronic Pain
☐ Other (Please state per concern)
Please describe your concerns
Section 3 – Medical History
Have you ever been diagnosed with:
☐ Cancer
Type
Year
Treatment received
⸻
☐ Diabetes
☐ High Blood Pressure
☐ Cholesterol
☐ Autoimmune Disease
☐ Thyroid Disease
☐ Chronic Infection
☐ Chronic Pain
☐ Cardiovascular Disease
☐ Liver Disease
☐ Kidney Disease
☐ Digestive Disorders
☐ Other (please state)
Current medications (please state)
Supplements (please state)
Herbs (please state)
Allergies (please state)
Section 4 – Lifestyle
(Please tick or/and describe)
Smoking
Never
Former
Current
Alcohol
Never
Occasionally
Weekly
Daily
Exercise
Never
1–2/week
3–5/week
Daily
Sleep
Excellent
Good
Poor
Irregular Sleep patterns?
Difficulty falling asleep?
Wake frequently?
Wake Multiple times for urination?
Wake tired?
Rapid or Vivid dreams? Nightmares?
Using Sleep pills?
Section 5 – Digestive Health (Very Important)
How is your appetite?
Excellent
Average
Poor
Do you experience:
☐ Acid reflux
☐ Bloating
☐ Gas
☐ Constipation
☐ Diarrhea
☐ Loose stool
☐ Blood in Stool
☐ Nausea
☐ Pain in abdomen
☐ Food intolerance
Bowel movements
Times per day?
Consistency?
Quantity and Quality?
Abnormal finding?
Section 6 – TCM Constitution Assessment
(Please tick the positive finding and rate the severity from 1 to 10 next to it )
Cold or Heat?
I usually feel
☐ Cold
☐ Hot
☐ Alternate
Hands & feet
☐ Cold
☐ Warm
☐ Hot
Do you sweat easily?
☐ Yes
☐ No
Night sweating?
☐ Yes
☐ No
Thirsty ?
☐ Yes
☐ No
Phlegm Pattern
Do you often have:
☐ Excess mucus
☐ Sticky saliva
☐ Heavy body
☐ Brain fog
☐ Dizziness
☐ Chest congestion
☐ Chronic sinus
☐ Overweight
☐ Fatigue after meals
☐ Greasy skin
☐ Oily scalp
☐ Multiple lipomas
☐ Frequent cysts
Fire / Heat Pattern
Do you experience:
☐ Mouth ulcers
☐ Bad breath
☐ Acne
☐ Red face
☐ Irritability
☐ Easily angry
☐ Bitter taste
☐ Dry mouth
☐ Constipation
☐ Dark urine
☐ Bleeding gums
☐ Red eyes
☐ Frequent inflammation
☐ Skin rashes
Qi Deficiency
☐ Easily tired
☐ Low energy
☐ Weak voice
☐ Shortness of breath
☐ Frequent colds
☐ Poor appetite
⸻
Blood Deficiency
☐ Pale complexion
☐ Dizziness
☐ Dry skin
☐ Hair loss
☐ Brittle nails
☐ Poor memory
⸻
Yin Deficiency
☐ Night sweats
☐ Dry mouth
☐ Dry throat
☐ Feeling hot at night
☐ Heat in chest, palms, soles of feet
☐ Dry eyes
_____________
Yang Deficiency
☐ Cold intolerance
☐ Edema
☐ Frequent urination
☐ Loose stools
☐ Low libido
Qi and Blood stagnation
☐ Chronic Pain, numbness or swelling
☐ Mass or growth
☐ Menstrual clots or Fibroids
☐ Chronic bruising
☐ Purple lips and nails
☐ PMS
☐ Dark menstruation blood
☐ Chest tightness
☐ Constipation
☐ Frequent sighing
☐ Distending Pain
☐ Stabbing Pain
☐ Frequent inflammation
☐ Emotionally stuck
__________
Internal Wind
☐ Headache or Vertigo
☐ Dizziness, Disoriented
☐ Shifting moods or pain
☐ Tremorish (hands,body parts or feelings)
☐ Lightheaded
☐ Irritability
☐ Stiff neck
☐ Muscle spasms or twitching
☐ Numbness
☐ Convulsions or seizures
☐ Bell’s palsy or hemiplegia
Section 7 – Emotional Well-being
How would you rate your stress from 0-10?
How would you rate your emotional wellbeing from 0–10?
Do you regularly practice:
☐ Meditation
☐ Yoga
☐ Qigong
☐ Breathwork
☐ Prayer
☐ Other (Please state)
Section 8 – Cancer Risk & Prevention Questionnaire
Note: This section is intended to identify lifestyle and medical factors that may influence overall health and prevention strategies. It is not a cancer screening or diagnostic tool.
Do you have a family history of:
(please tick if present):
• Breast cancer
• Colorectal cancer
• Lung cancer
• Prostate cancer
• Ovarian cancer
• Liver cancer
• Other (please specify)
Have you ever been told you have:
(please tick if present):
• Colon polyps
• HPV infection
• Chronic hepatitis B or C
• Barrett’s esophagus
• Chronic inflammatory bowel disease
• Other precancerous conditions (Please state)
Lifestyle factors:
(please tick if present):
• Smoking history
• Regular alcohol consumption
• Obesity or recent significant weight gain
• Low physical activity
• Diet low in vegetables and fruit
• Frequent processed or smoked food intake
• Excessive sun exposure without protection
Recent warning symptoms (please tick if present):
• Unexplained weight loss
• Unexplained weight gained
• Persistent fatigue
• Persistent pain
• Persistent discomfort
• Persistent cough
• Blood in stool or urine
• Difficulty swallowing
• New lump or swelling
• Persistent inflammation
• Change in bowel habits
• Persistent night sweats
• Persistent day sweats
Other warning symptoms experienced
(Please state)
Section 9 – Tongue, Facial and Palms Assessment:
Please upload two clear photographs and one 5 to 10 seconds video of your tongue
• Tongue (under natural light, before foods)
Please upload the additional photographs:
• Face (front view)
• Face (left side)
• Face (right side)
• Palm (left hand)
• Palm (left hand)
Section 10 – Consultation Goals
What are your three main health goals?
Others:
Section 11 – Consent
I confirm that the information provided is true and complete to the best of my knowledge. I understand that Traditional Chinese Medicine is complementary to conventional medical care and is not a substitute for emergency or specialist medical treatment. I agree to inform Dr. Mia Li of any changes in my medical condition or medications.
Name: ________________________
Signature: ____________________
Date: ________________________
Please state any other questions, issues, concerns or comments below: