1 About youSo your practitioner can match this questionnaire to your booking.
Full name *
Email *
Date of birth *
Appointment date (if booked) (optional)
Occupation (optional)
Do you have any allergies? Yes No
Please list your allergies (optional)
Any related family medical history? Yes No
List your family's medical conditions (optional)
2 Your constitutionIn Chinese medicine your general constitution matters as much as your main complaint. Pick the answer closest to you.
Do you feel hot or cold easily compared to average? I'm normal I am a cold person – I always need more layers than others. I am generally fine, but my hands / feet are cold. I am warm – I want to be cooler. I feel hot, and my hands / feet are always warm. None of the above – I will explain at the end
Do you sweat easily? Normal – I only sweat when I exercise. I sweat easily when I walk or go upstairs. My hands / feet are always wet. I sweat more at night / when I am asleep. I seldom sweat. None of the above – I will explain at the end
Do you have pain over the body? Yes No
Please explain the pain in your body (optional)
How is your diet? Good appetite and I eat regularly I eat on time, but don't really feel hungry Irregular – I eat only when I feel hungry I am vegan I am vegetarian I feel bloated often None of the above – I will explain at the end
What is your sleep like? Most nights I fall asleep easily and sleep through, with few dreams About 30% of nights I find it difficult to fall asleep; sometimes broken sleep and it takes a while to fall back; many dreams About 50% of nights I have problems falling asleep; broken sleep and I dream a lot I barely have good sleep I haven't been able to sleep through the night for a long while None of the above – I will explain at the end
How are your bowel movements? Regular; once a day; formed stool Regular; twice a day to once every two days; can be hard or soft Irregular; fewer than 3 a week Irregular; more than 2 a day Difficult; constipation None of the above – I will explain at the end
How is your energy level? ≈80% – I am good and exercise when I am free ≈60% – I just get through work and prefer to rest when I am free <50% – I'd take a nap if I could Fatigue – I feel very tired when I walk a bit longer None of the above – I will explain at the end
Is your period regular? I am on contraception Natural period & regular (26–32 day cycle) Natural period & irregular Painful PMS None of the above / not applicable
