Consultation Form(Cold,cough,flu,hay fever) Attention: Our website will not store any of your personal information. After completing the form, please click on the ‘submit’ button and send the PDF document via email, or take a photo and send it to your therapist.Full Name Date of birth Month Day Year Email Cold,Cough,Flu,Hay Fever for ______days Any drug allergy？ Chill and fever aversion to wind aversion to cold high fever mild fever alternative chill and fever cold hands cold feet Sweating no sweating mild sweating moderate sweating profuse sweating on the neck on the back on the chest on the head on the hands/palms on the feet/soles all over the body head headache dizzy heavy distending pain in the top of the head pain in the occipital pain in the frontal pain in the temporal nose feelings itchy dry blockage runny nose sneezing loss of smell nose discharge clear white yellow green with blood cough dry cough worse at night time worse with cold phlegm no phlegm profuse phlegm sticky phlegm clear phlegm yellow phlegm mix with white and yellow phlegm greenish phlegm phlegm with blood eyes symptoms red itchy watery pain swelling dry mouth not thirsty dry thirsty thirsty and prefer cold drink thirsty and prefer warm drink thirsty and want to drink more water thirsty but no desire of drinking water throat dry sore itchy difficult swallowing voice hoarse voice loss of voice chest chest tightness chest pain vexation shortness of breath wheezing palpitation Digestion&bowel movement vomit nausea poor appetite dry stool constipation loose stool diarrhea other symptoms all over the body ache tiredness skin rashes yellowish urination clear urination Practitioners onlyTongue,pulse,diagnosis,treatmentPulse: Tongue: Diagnosis: Treatment:HiddenSignatureName: Date:
