Clinical information sheet

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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

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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