Klinik Online

FORMULIR INFORMASI DAN DAFTAR PERTANYAAN

PASIENPERSONAL INFORMATION AND PATIENT QUESTIONNAIRE FORM

Silahkan lengkapi daftar pertanyaan dibawah ini. Informasi daftar pertanyaan ini sangat penting untuk solusi pengobatan anda guna mengoptimalkan ramuan tcm yang anda pesan sesuai dengan masing masing gejala sesuai dengan keluhan anda secara tepat.

Please take a few minutes to complete this questionnaire form below. These questionnaire information are very important and really helpful. It will be used to customize and optimize the basic herbal recipe by adding or removing some herbs to address your individual symptoms exactly.

Informasi Personal Pasien / Patient’s Personal Information

1. Patient's Personal Infomation

Full Name


Sex  Male female
Marital Status: (choose one)
 Single Married Divorced Widowed
Age
Weight: lbs.
Height:
Feet Inches
Email

2. Are you a vegetarian?
 NO Yes

3. How did you hear about us?


If other, please list below:

4. What is the chief problem that brings you to us?


IMPORTANT: We strongly recommend you to describe your symptoms here as detailed as you can, according to which some herbs might be added or removed in the basic recipe for the best efficacy by addressing the symptoms exactly

5. Indicate your subtype/ stage of of the disease if possible:

6. How long have you had the problem?

7. What do you think might be causing it?

8. What medication are you taking for the problem?

9. Do you have any allergies to medications?
 No Yes
If yes, please list the names of these medications and reactions to these medicines below:

10. Do you have any of the following medical conditions? (tick all that apply)
 hight pressureHigh blood pressure
 low pressureLow blood pressure
 high cholesteroHigh cholesterol
 previous strokePrevious stroke
 diabetesDiabetes
 asthmaAsthma
 kidney problemsKidney problems
 liver problemsLiver problems
 heart diseaseHeart disease

11. Do you have any of the following? (tick all that apply)
 feverFever
 high feverHigh fever
 persistent low feverPersistent low fever
 fever particular lyatnightFever particularly at night
 fever particular lyatnoonFever particularly at noon
 alternating fever and chillsAlternating fever and chills
 heat into leranceHeat intolerance
 cold sensitivityCold sensitivity
 chilly sensationChilly sensation
 cold extremitiesCold extremities
 cold backCold back
 warm and moist skinWarm and moist skin
 warm and moist palmsandsoleWarm and moist palms and sole
 Excessive sweating on hands and feetExcessive sweating on hands and feet
 Excessive sweating on faceExcessive sweating on face
 Excessive sweating on chestExcessive sweating on chest
 Excessive sweating in armpitsExcessive sweating in armpits
 Profuse sweatingProfuse sweating
 Spontaneous perspirationSpontaneous perspiration
 Soaking sweats at nightSoaking sweats at night
 AnhidrosisAnhidrosis

12. Do you have any of the following? (tick all that apply)
 headacheHeadache
 Sensation of heaviness in headSensation of heaviness in head
 LightheadednessLightheadedness
 SpinninggSpinning
 dizzinessDizziness
 Tinnitus (ear noises)Tinnitus (ear noises)
 Halos around lightsHalos around lights
 Blurred visionBlurred vision
 Eye painEye pain
 Gum swelling and painGum swelling and pain
 Parotid swelling and painParotid swelling and pain
 Sore throatSore throat
 Sore throat, relief with warmSore throat, relief with warm
 Sore tongue or mouthSore tongue or mouth
 Trouble chewing or swallowingTrouble chewing or swallowing
 Chest painChest pain
 Chest tightnessChest tightness
 Flank painFlank pain
 Abdominal painAbdominal pain
 aAbdominal pain, relief with warmAbdominal pain, relief with warm
 Abdominal pain, relief with pressureAbdominal pain, relief with pressure
 Abdominal tendernessAbdominal tenderness
 Cramping abdominal painCramping abdominal pain
 Back painBack pain
 Low back painLow back pain
 Cold low back with painCold low back with pain
 Cold and pain over lower abdomenCold and pain over lower abdomen
 Arm painArm pain
 Leg painLeg pain
 Pain or tiredness in the legs while walkingPain or tiredness in the legs while walking
 Limb weaknessLimb weakness
 Extremity numbnessExtremity numbness
 Numbness, tingling at night of arms or legsNumbness, tingling at night of arms or legs
 Upper extremity tremorUpper extremity tremor
 Lower extremity tremorLower extremity tremor
 HemiplegiaHemiplegia
 Painful jointsPainful joints
 Stiff jointsStiff joints
 Swollen jiontsSwollen jionts
 Falls, imbalance or difficulty walkingFalls, imbalance or difficulty walking
 Generalized achingGeneralized aching
 Generalized malaiseGeneralized malaise

12A. Do you have any of the following? (tick all that apply)
 FatigueFatigue
 WeaknessWeakness
 LassitudeLassitude
 LethargicLethargic
 TranceTrance
 ApathyApathy
 ForgetfulnessForgetfulness
 Emotional stressEmotional stress
 RestlessnessRestlessness
 Feel fear much of the timeFeel fear much of the time
 Feel anxious or depressed much of the timeFeel anxious or depressed much of the time
 PalpitationsPalpitations
 FretfulnessFretfulness
 IrritabilityIrritability
 ManiaMania
 Weak voiceWeak voice
 Loss of interest in talkingLoss of interest in talking
 Difficulty in sleepingDifficulty in sleeping
 InsomniaInsomnia
 DreamfulnessDreamfulness
 NightmaresNightmares
 Night terrorsNight terrors

14. Do you have any of the following? (tick all that apply)
 Short of breath hurryingShort of breath hurrying
 Short of breath walking up two flights of stairsShort of breath walking up two flights of stairs
 Short of breath just sitting or recliningShort of breath just sitting or reclining
 WheezingWheezing
 CoughCough
 Dry coughDry cough
 Cough with scant phlegmCough with scant phlegm
 Cough with copious phlegmCough with copious phlegm
 Cough with water phlegmCough with water phlegm
 Cough with mucopurulent (yellow) phlegmCough with mucopurulent (yellow) phlegm
 Cough with bloody phlegm (hemoptysis)Cough with bloody phlegm (hemoptysis)
 NosebleedNosebleed
 Nasal stuffinessNasal stuffiness
 RhinorrheaRhinorrhea

15. Do you have any of the following? (tick all that apply)
 Recent weight gainamountRecent weight gainamount: lbs.
 Recent weight lossamountRecent weight lossamount: lbs.
 Poor appetitePoor appetite
 Frequent thirst with desire for drinkingFrequent thirst with desire for drinking
 Frequent thirst without desire for drinkingFrequent thirst without desire for drinking
 PolydipsiaPolydipsia
 Parching lipsParching lips
 Dry mouthDry mouth
 Decreased salivationDecreased salivation
 Increased salivationIncreased salivation
 Bitter mouthBitter mouth
 Mouth odorMouth odor
 NauseaNausea
 VomitingVomiting
 VomituritionVomiturition
 HematemesisHematemesis
 HiccupsHiccups
 BelchingBelching
 Bowel sounds (flatulence)Bowel sounds (flatulence)
 Abdominal distentionAbdominal distention
 AscitesAscites
 JaundiceJaundice
 Liver cirrhosisLiver cirrhosis
 Frequent indigestionFrequent indigestion
 Heartburn (pyrosis)Heartburn (pyrosis)
 RegurgitationRegurgitation
 StomachacheStomachache
 Stomach ulcerStomach ulcer
 Stomach bleedingStomach bleeding

16. Do you have any of the following? (tick all that apply)

 Change in bowel habitsChange in bowel habits
 Dry and hard bowel movementsDry and hard bowel movements
 Loose bowel movementsLoose bowel movements
 Alternating hard and loose bowel movementsAlternating hard and loose bowel movements
 Black or bloody bowel movementsBlack or bloody bowel movements
 Purulent bowel movementsPurulent bowel movements
 DiarrheaDiarrhea
 Bloody diarrheaBloody diarrhea
 ConstipationConstipation
 Scant deep yellow urinatingScant deep yellow urinating
 Copious clear urinatingCopious clear urinating
 Cloudy urinating and mucus productionCloudy urinating and mucus production
 HematuriaHematuria
 Urinary frequencyUrinary frequency
 Urinary urgencyUrinary urgency
 Pain during urinationPain during urination
 Burning during urinationBurning during urination
 Dribbling of urineDribbling of urine
 Urinary hesitancyUrinary hesitancy
 Slow urinary streamSlow urinary stream
 Sensation of incomplete bladder emptyingSensation of incomplete bladder emptying
 Difficulty urinating (dysuria)Difficulty urinating (dysuria)
 EnuresisEnuresis
 Lose control of urine at timesLose control of urine at times
 TenesmusTenesmus
 Anal burningAnal burning
 Anal burning painAnal burning pain
 Anal pruritusAnal pruritus

17. Do you have any of the following? (tick all that apply)

 Anal pruritusDry and lusterless hairAnal pruritusDry and lusterless hair
 Anal pruritusPrematurely gray-hairedAnal pruritusPrematurely gray-haired
 Anal pruritusSparse scalp hairAnal pruritusSparse scalp hair
 Anal pruritusRed eyeAnal pruritusRed eye
 Anal pruritusFlushed faceAnal pruritusFlushed face
 Anal pruritusPallorAnal pruritusPallor
 Anal pruritusSallow complexion (ochriasis)Anal pruritusSallow complexion (ochriasis)
 Anal pruritusLivid lipsAnal pruritusLivid lips
 Anal pruritusLivid changes in nailAnal pruritusLivid changes in nail
 Anal pruritusLusterless nailsAnal pruritusLusterless nails
 Anal pruritusItchy skin (pruritus)Anal pruritusItchy skin (pruritus)
 Anal pruritusEdemaAnal pruritusEdema


18. Women Only
---- Do you have any of the following? (tick all that apply)

 Painful menstruationPainful menstruation
 AmenorrheaAmenorrhea
 Menstruation disordersMenstruation disorders
 Scanty flow (oligomenorrhea)Scanty flow (oligomenorrhea)
 AMenorrhagiaMenorrhagia
 Heavy periodHeavy period
 Prolonged periodProlonged period
 Menstrual blood clotsMenstrual blood clots
 Bleeding between periodsBleeding between periods
 Bleeding after menopauseBleeding after menopause
 Mucopurulent (yellow) vaginal dischargeMucopurulent (yellow) vaginal discharge
 Watery vaginal dischargeWatery vaginal discharge
 Foul vaginal dischargeFoul vaginal discharge
 Any breast dischargeAny breast discharge
 In pregnancyIn pregnancy
 In lactationIn lactation


19. Men Only
---- Do you have any of the following? (tick all that apply)

 Warm and moist scrotumWarm and moist scrotum
 Sweating scrotiumSweating scrotium
 Premature ejaculationPremature ejaculation
 Weak erectionWeak erection
 Erectile dysfunction (impotence)Erectile dysfunction (impotence)
 SpermatorrheaSpermatorrhea
 Excessive sexual driveExcessive sexual drive
 Loss of sexual desireLoss of sexual desire


20. In this section you need to use your mirror or have someone help you watch your tongue.

Tongue watching is a special feature and takes an important part in using Chinese herbs correctly. Tongue appearance reflects lots of information about our body on the influence by and response to heat, cold, wet, and dry in the natural environment. In China it is a routine inspection commonly used by the practitioners in this field. Well, stick out your tongue and look in the mirror or have someone help you watch it. Compare the given samples below with yours and tick one that best represents your tongue and tongue coating . If you are not sure please skip this section.

Which of the following best represents your tongue and tongue coating? (choose one that best apply)

 Not sure Sample # 01: Light red tongue with thin and white tongue coating Sample # 02: Red tongue with little or without tongue coating Sample # 03: Deep crimson tongue with little or without tongue coating Sample # 04: Cracked, dry and crimson tongue without tongue coating and saliva Sample # 05: Tender, wet and light red tongue with thin and white tongue coating Sample # 06: Tender, enlarged and light red tongue with white tongue coating Sample # 07: Light red tongue with thick and white tongue coating

If none of the above represents yours please describe your tongue and tongue coating below:

Use the attach file below for upload the image of your tongue or your additional documentation, if any.


Allowed file:
zip,doc,pdf

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