0.  性别 ： 年龄： 职业： 省份： 身高： 体重： 面色：
1. 主要症状：起病经过：（按时间顺序叙述，越详细越好）
2. 局部病变（皮肤病、疮疡、外伤患者需填此。包括局部颜色、肤温、有无肿胀、肿块、质地等）
3. 曾经得过何种疾病？何时何地？如何治愈？是否复发？
4. 心胸情况：（有无胸闷？心慌？心悸？胸痛？心中发紧否？心区痛？气急？气喘？）
5. 腰背：（疼否？酸否？重否？如压大石否？）
6. 小腹：（发凉否？发热否？胀否？痛否？ 有无膨隆？肠鸣否？ 腹部有无静脉曲张？）
7. 两胁：（痛否？胀否？）
8.  腿： （凉热？痛否？内侧外测？筋紧否？无力否？骨发空否？站立觉累否？是否静脉曲张？前后左右？）
9.  足：（凉热？麻否？跟痛否？左右）

10.   眼：（视力，红肿痛否？干涩否？胀否？程度与时间？
11.   问睡眠,你的睡眠如何?是否一觉到天亮?是否每天定时会醒?如果会醒,是几点会醒?是否多梦?等等.
12.   问胃口,你感觉饿吗?有欲望想吃什么特别的食物或是喜爱什么味道的食物?或是不饿,完全没有胃口.
13.   问大便,你便秘吗?每天有大便吗?大便颜色是什么?是下利吗?很臭还是无味?等等.
14.   问小便,你的小便是什么颜色?频尿吗?还是小不出来?还是没有尿意?平均一天几次?等等.
15.    问口渴,你很渴吗?如渴,最想喝什么温度的水?如不渴,时常会忘记喝水吗?还是再怎么喝也不能止渴呢?
16.    问寒热,你平时觉得身体很热还是很冷?手脚冰冷吗?
17.    问汗,你容易出汗吗?会半夜盗汗吗?会时常流汗不止吗?还是不出汗的身体呢?
18.    问体力如何,精神好吗?还是一直疲惫中?早上起床时,是精神奕奕呢?还是无法起床呢?精神能够集中吗?
19.    问性功能,你性功能好吗?等等.
20.    问女子月经,无论妳有无月经,都要详细说明妳的月经情形,是延后还是每次都提前呢?痛不痛呢?生过小孩吗?
        白带情况：（多？少？稀？稠？颜色黄？白？有无腥臭？）

Appetite胃口
Do you feel hungry at: Breakfast? Lunch? Dinner?
早餐,中餐,晚餐,會感到餓嗎?
How is your ability to taste food?
對食物的味覺能力如何?
Do you consume small, moderate, or large amounts of food at mealtimes?
用餐時, 食量如何, 大? 中? 小?
Do use sea salt in your cooking. Do not use refined sugars. Eat like a king for breakfast, a prince for lunch, and a pauper for dinner.
烹調時務必使用海鹽, 禁用精製糖.
早餐吃的像皇帝, 中餐吃的像王子, 晚餐吃的像貧民,
Sleep睡眠
Are you able to sleep through the entire night without waking up?
一夜好眠?
Do you feel adequately rested upon rising?
起床時,覺得休息夠了?
Additional comment concerning your sleep pattern:
其他有關於你睡眠的描述
Urine尿
Do you urinate approximately 5 to 7 times per day?
每天尿5到7次?
What is the color of your urine?
尿液的顏色?
Is your urine clear or cloudy?
尿液清或濁?
Do you take vitamins? If so stop taking them, they only feed the flies.
服用維他命? 如有的話,請停用,那是餵蒼蠅的
Do you have a small, moderate, or large amount of urine?
尿量如何? 多? 中等? 少?
Is there adequate force when urinating?
排尿有力嗎?
Additional comments or concerns about your urine:
其他有關於你尿液的描述
Bowel大便
Do you have a bowel movement at least once a day in the morning?
每天至少早上屙1次?
Is the texture of your stools firm and long?
糞便是緊實且長?
What is the color of your stools?
糞便的顏色?
Do you have the feeling of having adequately emptied your bowels?
感覺屙的乾淨嗎?
Additional comments or concerns about your bowel:
其他有關於你的糞便描述
AM Yang早晨陽反應
(MALES) Do you have an erection upon waking first thing in the morning?
(男)早晨醒來有勃起?
(FEMALES) Are your nipples erect upon waking first thing in the morning?
(女)早晨醒來乳頭有勃起?
Four Limbs四肢
Does your forehead feel cool and comfortable compared to the temperature of your hands?
額頭比手涼, 且感到舒服?
Does the back of your hands and tops of your feet feel cooler than the palms and soles?
手背及腳背比掌心及足心涼,?
Do you have to keep your feet covered at night?
晚上腳要蓋在被子裡?
Thirst渴
Do you have any type of abnormal thirst? Note that it is normal to have some thirst after sweating from exertion. The amount of thirst that you have should be in proportion to your activity level and the environment.
不正常口渴? ?注意:勞動流汗後的一般口渴是正常的.口渴的程度是與活動程度及環境成比例的
Do you prefer warm, room temp, cool, or cold water?
喜熱飲? 喜室溫飲?喜冷飲? 喜冰飲?
Drinking hot teas is good for your body. The fluids in fruits do more to rehydrate your body than drinking anything.
熱茶有益身體, 水果中的液體比任何東西更能補充水分
Sweat汗
Do you have any type of abnormal sweating? Like sweating for no reason or night sweats.
任何不正常的流汗? 像是盜汗或夜汗?
Can you sweat?
會流汗嗎?
Pains痛
Do you have any pains in your legs, arms, back, etc?
腿, 臂, 背或任何特疼痛?
If so do you know what caused them (accident for instance)?
如有, 起因為何?(例:意外)
How long have you had these pains?
痛多久了?
Does pressure or touch make your pains feel better or worse?
壓或觸碰是加劇或減緩疼痛?
Other Comments:
其他
List any other symptoms, concerns, and questions here.
其他症狀, 顧慮, 問題