TCM Initial Intake & Constitutional Assessment

This intake form gathers your full medical, lifestyle, and constitutional background so the practitioner can perform an accurate pattern differentiation and design a personalised TCM plan. Please answer as completely as you can — every detail helps.

Patient Information

Full name:

Date of birth:

Gender:

Female

Male

Non-binary / other

Prefer not to say

Occupation:

Height (cm):

Weight (kg):

Phone:

Email:

Emergency contact (name & phone):

Chief Complaint

Main reason for visit — describe in your own words:

Duration (e.g. 3 weeks, 2 years):

Severity right now (0 = none, 10 = worst):

History of Present Illness

When did the symptoms start, and how have they evolved?

Aggravating factors (what makes it worse):

Relieving factors (what makes it better):

Previous treatments tried (Western, TCM, supplements, self-care):

Past Medical History — Western

Chronic conditions (check all that apply):

Hypertension

Diabetes

Cardiovascular disease

Asthma / respiratory disease

Autoimmune disease

Cancer history

Past surgeries

Details on any of the above:

Current medications (name, dose, frequency):

Known allergies:

Past Medical History — TCM

I have received TCM treatment before

If yes, what was treated and what worked / did not work:

Previous practitioner / clinic (if any):

Known herbal sensitivities or past adverse reactions:

Eight Principles Assessment

Yin / Yang tendencies:

More yin (cold, quiet, withdrawn)

Balanced

More yang (hot, active, restless)

Cold / heat:

Feel cold often (cold limbs, prefer warmth)

Feel hot often (warm body, prefer cool)

Mixed / alternating cold and heat

Deficiency / excess:

Deficiency signs — fatigue, pale, low voice, weak pulse

Excess signs — strong pain, fullness, loud voice, forceful pulse

Interior / exterior pattern:

Exterior — recent, surface symptoms, related to weather/cold

Interior — chronic, organ-related, deeper symptoms

Brief notes on the above:

Five Elements Tendencies

Predominant element (check the one that fits best):

Wood — Liver / Gallbladder

Fire — Heart / Small Intestine

Earth — Spleen / Stomach

Metal — Lung / Large Intestine

Water — Kidney / Bladder

Common emotional patterns (check all that apply):

Irritability / anger (Wood)

Anxiety / restlessness (Fire)

Overthinking / worry (Earth)

Grief / sadness (Metal)

Fear / startle (Water)

Constitutional notes:

Sleep & Energy

Sleep onset:

Falls asleep easily

Difficulty falling asleep

Lies awake for 30+ minutes

Wake-ups during the night:

None — sleeps through

Wakes once

Wakes 2–3 times

Wakes frequently and cannot return to sleep

Dreams:

Vivid

Disturbing / nightmares

Minimal / rarely remembers

Energy throughout the day:

Morning low — slow to start

Afternoon dip

Evening fatigue

Steady all day

Overall fatigue level (0 = none, 10 = severe):

Diet & Digestion

Appetite:

Strong

Normal

Poor

Variable

Favourite tastes (check all that apply):

Sweet

Salty

Sour

Bitter

Pungent / spicy

Digestion:

Bloating after meals

Acid reflux / heartburn

Heaviness / sluggishness after eating

Bowel pattern:

Regular daily

Loose / soft

Hard / dry / constipated

Alternating loose and hard

Thirst:

Little thirst

Normal

Strong thirst — drinks a lot

Cold / warm food preference:

Prefers cold food and drinks

Prefers warm / hot food and drinks

Urination

Daytime frequency:

Less than 4 times

4–6 times

7–10 times

More than 10 times

Wakes at night to urinate (nocturia)

Number of nocturia episodes per night:

Colour:

Clear / pale

Yellow

Dark / concentrated

Sensation:

Burning

Urgency

Weak / dribbling stream

Menstrual / Gynecological History (if applicable)

Cycle length (days):

Flow:

Light

Moderate

Heavy

Clots present

Menstrual pain (0 = none, 10 = severe):

PMS symptoms (mood, breast tenderness, cravings, etc.):

Number of pregnancies:

Number of live births:

Lifestyle

Occupational stress (0 = none, 10 = extreme):

Exercise frequency:

None / sedentary

1–2 times per week

3–4 times per week

Daily

Smoking

Alcohol — occasional

Alcohol — regular

Recreational substances

Environmental exposures (chemicals, dust, cold, damp, etc.):

Emotional State

Recent emotional patterns — moods, triggers, frequency:

Stress level (0 = none, 10 = overwhelming):

Goals for TCM Care

What outcomes would you like from this course of TCM care?

Acknowledgement

The information I have provided is accurate to the best of my knowledge

I am willing to follow lifestyle and dietary recommendations

I understand that TCM is complementary to — not a replacement for — Western medical care

Thank you. Your practitioner will review these answers before your consultation and integrate them with pulse and tongue diagnosis to design your personalised care plan.