Constitutional intake, pattern differentiation and treatment plan, treatment session records, herbal prescriptions, and course completion follow-ups for Traditional Chinese Medicine clinics and licensed TCM practitioners
Get started with PocperThis 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.
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):
Main reason for visit — describe in your own words:
Duration (e.g. 3 weeks, 2 years):
Severity right now (0 = none, 10 = worst):
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):
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:
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:
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More yin (cold, quiet, withdrawn)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:
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 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):
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
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
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:
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.):
Recent emotional patterns — moods, triggers, frequency:
Stress level (0 = none, 10 = overwhelming):
What outcomes would you like from this course of TCM care?
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.
The TCM Initial Intake & Constitutional Assessment template is a ready-to-use form from Pocper's TCM Clinic pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.