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Name ……………………………………. First name …………………
Birth date (or age) ……………. Weight: …………………..
Profession ……………………………… Size:
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Reason for the consultation / Symptoms on which you wish to act / possible Diagnostic:
………………………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………..
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Clinical signs of orientation: keep only the obvious symptoms, if it is a question with several choices, surround the important symptom (the words in italics are codes for the expert).
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Causality… O Cold, traumatism O Moisture (snow, storm, fog)
O Heat on stagnation (itchings) O Disappointment, humiliation
O Dryness (and local acidity?) O Vascular attack, high fever
………………….
…
Metabolic set of organs (Liver / Gallbladder / Muscles and tendons – MTC: Yang + wind)
O Emotional person: timidity, disappointment… O Fear (attacks of panic)
O Angry O Cramps / Spasms
O Sensitive to cold (but improved by movement) O Tendinitis / Periarthritis / with derusting?
O Weakened (low Ferritin ?) O Conjunctivitis (red eyes)
O Hemorrhoids (protruding/bleed)
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Dystonic set of organs … (Lungs / Colon / mucocutaneous surfaces – MTC: Qi)
O Over-sensitiveness with the external influences and ideas
O Sadness: melancholy, cries, spasmophile… O Constipation (> at 2 days)
O Impatience and intolerance with frustration, addictions ?
O Tired (and worsened by the physical exercise) O varicose veins / Cellulitis
O Mucous infections: ORL repeated (anginas/otitis/ Sinusitis) / Bronchitis…
O Dermatology: common acne / Boils / Psoriasis / Fungal infection / Vitiligo… (surround)
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Lymphoid set of organs … (Spleen / pancreas / stomac – MTC: Lymph + moisture)
O Anorexia / Bulimia / Diet (surround) O Memory problems
O Obsessions / constant worries O Tremors / Tics
O Diarrhea (> 6 bowel per day) O Tropical disease (paludism, amoebas…)
O Multiple Lipomas / Warts O Mastosis (cysts/balls)
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Acid phase… (localized inflammation on dryness) O uncertainties, loss of the reference marks
O Mouth ulcers / Gingivitis / Periodontitis O recurring Herpes / Shingles
O Aerophagia / Stomach pain / Ulcus O Hematomas easy / Purpura
O Anal crack / Fistula – Varicose ulcer O Gout
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Vascular set of organs … (Heart – vessels – MTC: Blood + fire)
O Strong anxiety / Anguishes O Concern excessive of the wellbeing of others?
O Insomnia: start / 2nd part of night O Thyroid disease: …………..
O Disorders of the cardiac rhythm O hot flashes
O Malleolar edema (the ankles inflate) O Hyper or hypo blood pressure: ………
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Demineralized set of organs… (Kidney-bladder / conjunctive tissues – MTC: Yin – Water)
O Depression: don’t want anything, discouragement O Vertigo
O Impotence / Frigidity O Buzzes of ears
O Prostatic adenoma / uterine fibroid O renal lithiasis / repeated cystitis
O Fall hair O Ostéoporose
O Osteoarthritis: cervical, dorsal, lumbar, sciatic nerve, hip, knees (surround)
Female symptoms :
O Contraceptive pill or substitute hormonal treatment (menopause)
You are rather worse… O before periods O at the arrival of periods O after periods
O Dysmenorrhoea (painful rules) O Vaginal discharge / Bartholinite
O Pregnancy / breast feeding in progress O abundant Rules
Many pregnancies …………. O Previous of I.V.G. /of false-layers
O Hysterectomy (total or with conservation of the ovaries?)
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Various intoxications:
O Tobacco (+ 10 cigarettes/day) O Alcohol (+ of ½ liter wine/day)
O Tranquilizer / Sleeping pill / Antidepressants / Beta-blockers (surround)
O Recent vaccines (< at 10 years): Covid19 / Hepatitis A/B / Yellow fever / Typhoid ….
O Lipid-lowering agents (cholesterol) / mmunosuppressant / Chemotherapy / Radiotherapy
O Corticosteroid therapy (in progress or recent) / Anti-inflammatory drugs
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Tongue … Saliva O rare, absence O too abundant
Coating O thin, absent (geographical) O thick (white – yellow)
Body O cracks (dryness) O spikes (small buttons red)
Mouth … O Bitter mouth (heat) O Pasty (moisture)
O Sour taste (retention) O Loss of taste (spleen vacuum)
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Personal history (dates PLEASE for surgery) and para-clinics examinations:
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Sought-after flavors: O acid O bitter O sweetened O prickly O salted
Allergies: O pollinose O migraine O urticaria O asthma O eczema
O Food intolerances with: …………………………………………………
O Atopie (beginning by eczema before the 6 months age)
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Evaluation (worsens): O movement O heat O moisture O pressure O is thirsty
“ (what improves): O movement O local heat O moisture O local press. O no thirst
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Family history: O hyperlipemy O hyperT O diabetes O drips O rheumatisms
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Pains (to be filled only if you are in pain):
O Abrupt start (external cause) O Gradual onset (intern causes)
O The pain is intense (plenitude) O Dull pain (empty)
O Erratic pains, continuation of efforts, emotions, weather change (wind)
O Frilosity, stiffnesses (morning derusting), intense unilateral pain (cold)
O Swelling, fixed localization and heaviness of the zone (Humidity, Qi vacuum)
O In “stab” (glaires) O Hot, red and inflated Zones (heat)
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Worse pains: O day (Qi) O night (stagnation) O after the meal (phlegm)
O Dental care in progress or recent O Scars/recent operations
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Psychological behavior dominating/recurring concern:
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Date and code of the last BNS / BNT
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